Occupational Medicine Advance Access originally published online on August 11, 2006
Occupational Medicine 2006 56(7):497-500; doi:10.1093/occmed/kql086
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SHORT REPORT |
Evaluation of a functional restoration programme in chronic low back pain
1 RehabWorks Ltd, St Andrews Street South, Bury St Edmunds, Suffolk IP33 3PH, UK
2 Workfit, The Old Bakery, St Andrews Street South, Bury St Edmunds, Suffolk IP33 3PH, UK
3 MRD Ltd, c/o RehabWorks Ltd, St Andrews Street South, Bury St Edmunds, Suffolk IP33 3PH, UK
Correspondence to: Nicola Hunter, RehabWorks Ltd, St Andrews Street South, Bury St Edmunds, Suffolk IP33 3PH, UK. Tel: +44 1284 748285; fax: +44 1284 748289; e-mail: nicola{at}rehabworks.co.uk
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Abstract |
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Background Persistent low back pain is a major health and socio-economic problem in the UK. Evidence-based guidelines have been produced to inform management strategies for this significant health issue. This study reports the outcome of a tertiary intervention functional restoration programme (FRP) in manual workers of a water utility company, consistent with UK guidelines.
Objectives To evaluate whether a FRP could achieve a sustainable improvement in back health, a sustainable return to full duties and a cost reduction.
Method Participants were assessed at start, end, 12 and 24 months post-programme.
Results Eighty-nine employees completed the FRP; 78 returned to normal duties, nine to restricted duties and two left the employer shortly after. Overall, there were significant improvements in psychological status, perceived pain, disability and work capability. Improvements were sustained for 24 months. Sickness absence and the need for post-treatment work restrictions decreased. Reductions in ill-health retirements and compensation claims for low back pain were reduced.
Conclusion The findings support the effectiveness of a tertiary intervention FRP for workers with persistent low back pain.
Keywords Functional restoration programme; ill-health retirement; low back pain; perceived pain and disability; return to work; sickness absence
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Introduction |
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This paper reports the outcome of a functional restoration programme (FRP) implemented in a UK utilities company, as part of a three-stage evidence-based strategy to manage low back pain [1,2].
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Method |
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A longitudinal study utilizing pre- and post-programme measurement, with follow-up at 12 months (reassessment) and 24 months (postal questionnaire).
Participants were referred to the programme if they were not fit for full duties 6 weeks after the onset of low back pain and remained, off work due to back pain, required specific lifting restrictions or were taking repeated short absences or reporting back problem affected their work and health, despite treatment.
The following outcome measures were used to determine the effectiveness of the FRP.
- (i) Numeric pain rating scale (NPRS), a two-point difference represents a clinically meaningful change [3].
- (ii) The Oswestry disability index (ODI) [4], a change of 8–12% indicates a clinically significant change in back pain disability [5].
- (iii) Acute pain screening questionnaire (APSQ) [6], to identify biopsychosocial issues.
- (iv) Epic Spinal Function Sort (EPIC) [7], to measure self-efficacy and perceived work capability.
- (v) Dynamic leg lift test [8] and National Institute for Occupational Safety and Health static strength tests [9], to measure change in physical performance for simulated work activities.
- (ii) The Oswestry disability index (ODI) [4], a change of 8–12% indicates a clinically significant change in back pain disability [5].
The cost benefit of the programme was calculated using FRP billing information. Sickness absence data for 24 months pre- and post-programme were obtained from human resources. Compensation claims from 1998 to 2004 and ill-health retirement (IHR) data from 1998 to 2004 were also obtained. The data were analysed using SPSS for Windows statistics package version 13.
The participant's physical, psychosocial and functional capability was assessed. Employees joined the FRP on a rolling basis, attending 1 day a week for a minimum of 4 and a maximum of 12 weeks. Employees commenced a graduated return to full duties concurrent with the FRP. The programme was delivered by chartered physiotherapists adhering to a procedural manual. The FRP comprised aerobic exercise, graded flexibility and strength training, work conditioning and education and job-specific training to facilitate self-management and safe working practices.
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Results |
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Eighty-nine employees were referred to the FRP (84 males and 5 females—workforce majority male manual) between April 2000 and December 2002. All consented to inclusion in the study. All had received treatment for back pain from their general practitioner, physiotherapist, osteopath or chiropractor. The mean age was 41 years (range 21–61 years). Fifty-nine attended for reassessment at 12 months; 53 completed questionnaires at 24 months. During the study period, 18 employees left the company under transfer of undertakings and protection of employment (TUPE) due to outsourcing of services.
The significance of changes in psychological (perceptions of pain and disability) and physical capability was assessed by t-test and analysis of variance (ANOVA) (Table 1 selected results).
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NPRS results showed that the result for worst pain experienced reduced over the 24-month period (F = 9.93, P < 0.001) and the change remained significant at each time point as measured by t-test analysis. It also reduced beyond two points suggesting a clinically meaningful change [3].
ODI scores decreased immediately post-programme from moderate disability to mild disability (t = 10.24, P < 0.001). The difference between pre-programme scores, scores at 12 months (t = 7.13, P < 0.001) and at 24 months (t = 4.28, P < 0.001) remained significant. The change in mean scores indicated a clinically significant change in the level of disability [5].
APSQ decreased and the difference between pre- and post-programme scores was significant (t = 8.11, P < 0.001). This was sustained at 12 months (t = 5.33, P < 0.001) and at 24 months (t = 6.43, P < 0.001).
EPIC scores improved post-programme (t = –6.91, P < 0.001), and the difference between pre-programme scores and 12 months later was still significant (t = –6.48, P < 0.001).
A repeated measures ANOVA calculation found that NIOSH static strength results increased immediately post-programme and the increase was sustained at 12 months: arm lift (F = 3.76, P < 0.03), leg lift (F = 24.6, P < 0.001), high near lift (F = 15.64, P < 0.001), high far lift (F = 15.9, P < 0.001). Dynamic leg lifting capability also increased (F = 34.19, P < 0.001).
Work status pre- and post-programme is summarized in Table 2. Absence attributable to musculoskeletal causes reduced from a mean of 17.3 days per person in the 24 months pre-programme to a mean of 5.8 days in the 24 months post-programme. The results of within subjects, t-test, suggested that the change was significant at 24 months (t = 3.14, P < 0.002). Ten employees exceeded 5 days off in the 24 months post-programme. This group accounted for 89% of the days lost post-programme. Sickness absence was costed at £115 a day [10]. The mean cost per employee for sickness absence in the 24 months pre-programme was £1988. In the 24 months post-programme, this reduced to £618. The average cost of the FRP for each participant was £917 per person. Assuming sickness absence would have continued, or increased over time, without active intervention, there appears to be a cost saving to the company.
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IHR data for 3 years pre-programme (1998–2000) and for 3 years post-programme (2001–2004) showed that the number of IHRs for back pain reduced from 7 to 2. IHRs for other musculoskeletal disorders (MSDs) also reduced from 8 to 4 during the same period. Claims data showed a decline in the number and value of the claims for back pain compared to other causes since the programme started in mid-2000 (Table 3).
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Discussion |
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The results of this study indicate that the FRP achieved a significant improvement in the back health of participants. The effect appears to persist for a 24-month period for the majority (88%).
There was a sustainable return to full normal work duties for the majority. However, 10 employees continued to take time off. These accounted for 89% of the post-programme absence. A detailed case review revealed that the six employees who took >30 days absence in the 24 months post-programme, had ongoing, non-physical work-related issues.
Claims and IHR data showed a declining trend, suggesting that a FRP that is effective in restoring work capability may reduce the need for IHR and the potential for a claim.
A major limitation of this study was the lack of a control group. It is not known if changes were due to the intervention or other factors. However, it was not in the business's interest to withhold treatment, reported in the literature to improve health and hasten return to work.
In summary, the findings of this study suggest that FRPs can play an important part in the recovery from back pain.
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Conflicts of interest |
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TopAbstractIntroductionMethodResultsDiscussionConflicts of interestReferences |
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None declared.
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References |
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- Carter JT, Birrell LN, eds. Occupational Health Guidelines for the Management of Low Back Pain at Work—Principal Recommendations. London: Faculty of Occupational Medicine, 2000.
- Guzmán J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary bio-psycho-social rehabilitation for chronic low back pain (Cochrane Review). In: The Cochrane Library. Chichester, UK: John Wiley & Sons, Ltd, 2004.
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- Matheson LN, Matheson ML, Grant J. Development of a measure of perceived functional ability. J Occup Rehabil 1993;3:15–30.
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- Health & Safety Executive Website. Ill Health Cost Calculator. http://www.hse.gov.uk/costs/ill_health_costs/ill_health_costs_calc.asp (date last accessed 1 August 2006).
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