Occupational Medicine Advance Access originally published online on October 17, 2006
Occupational Medicine 2007 57(1):36-42; doi:10.1093/occmed/kql102
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Evidence-based care for low back pain in workers eligible for compensation
Department of Clinical Research, University of Newcastle, Royal Newcastle Hospital, Newcastle, New South Wales, Australia
Correspondence to: Brian McGuirk, Newcastle Bone and Joint Institute, Department of Clinical Research, Royal Newcastle Centre, Locked Bag 1, New Lambton, NSW 2300, Australia. Tel: +61249223505; e-mail: michelle.gillam{at}newcastle.edu.au
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Abstract |
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Background Although guidelines for the management of low back pain have been promoted, few studies have assessed their effectiveness. One previous study did not include patients with workers' compensation claims.
Aim To assess the efficacy of evidence-based care for acute low back pain in patients eligible for workers' compensation.
Methods In a prospective audit, workers in a health service who presented with acute low back pain were offered the option of usual care from their general practitioner or care provided by a staff specialist who practiced according to evidence-based guidelines. Outcomes were measured in terms of return to normal duties, time off work, recurrence of pain or persistence of pain.
Results Evidence-based care was accepted by 65% of injured workers. Compared with those who elected usual care, these workers had less time off work, spent less time on modified duties and had fewer recurrences. A significantly greater proportion (70%) resumed normal duties immediately, and fewer developed chronic pain, than those managed under usual care. Three types of patients were identified: those who complied readily with evidence-based care, those who initially expressed firm beliefs about how they should be managed and those with occupational psychosocial factors.
Conclusions Evidence-based care can be successful in retaining patients at work, reducing time off work or on modified duties and reducing recurrences and chronicity. The gains are achieved by conscientiously talking to the patients, and not by any particular or special passive interventions.
Keywords Back pain; evidence-based; guidelines; treatment
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Introduction |
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Many authorities have produced evidence-based guidelines for the management of acute low back pain [1–7]. Some have been developed explicitly for the management of workers with back pain [8,9,10]. No studies, however, have evaluated the efficacy of management, according to guidelines, of back pain in injured workers.
One study reported that evidence-based practice, when compared with usual care, resulted in slightly, but significantly, better clinical outcomes, and substantially less use of imaging and drugs, significantly less chronicity and greater patient satisfaction [11]. That study, however, was limited to patients who were not eligible for workers' compensation. The favorable outcomes, therefore, might have been due to the selection of patients whose outcomes were not confounded by compensation issues.
The present study was undertaken to redress this deficiency in the literature. It was designed to provide prima facie evidence of how effective evidence-based care can be in a workers' compensation setting.
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Methods |
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The study was conducted in two district hospitals and two teaching hospitals in the city of Newcastle, in New South Wales, Australia. For these four hospitals, a service was established in which a staff specialist (an occupational physician with postgraduate training in musculoskeletal medicine) was appointed to be available for consultation by any member of staff who suffered a low back injury while at work. The specialist practiced according to the Australian evidence-based guidelines for the management of acute low back pain [7]. These guidelines are similar to other, previously published guidelines, save that they do not entertain treatment by manual therapy. In essence, they emphasize explanation, assurance, encouragement to remain at work, a worksite intervention if indicated, simple analgesics if required and avoidance of passive therapies. Imaging is indicated only in the presence of clinical red flag indicators. Instructions on how to implement these guidelines have been elaborated elsewhere [12].
Under workers' compensation legislation in the state of New South Wales, workers who believe that they have sustained an injury are obliged to report the incident. Reporting an incident results in a potential workers' compensation claim being registered, but not necessarily pursued. Claims are activated only if workers incur medical costs or lost time from work. Workers can pursue medical care privately, or can avail themselves of services provided by their employer.
In the present study, incidents were registered by the staff health nurse in each hospital. The nurse informed patients that they could elect to see the staff specialist or to pursue care privately with a general practitioner of their own choosing. No information was provided to workers that the staff specialist practiced in any particular manner, or that he practiced according to evidence. Workers were simply given the opportunity to see either him or their own practitioner.
The staff specialist saw the injured worker at a staff health clinic, most often on the day of injury or on the next working day. Rarely did 48 h elapse before the worker was seen. At the consultation, the staff specialist took a history of the immediate injury, and a general medical history. He administered a red flag checklist [11,13]. He examined the patient to exclude neurological signs, and nominally to identify any tenderness and restricted range of motion. In the absence of red flag indicators, he initiated a plan of management. The core of that plan is summarized in Appendix.
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Management consisted primarily of an explanation of the nature of acute low back pain, its benign nature and good prognosis [14,15]. Any fears or misconceptions that the patient had were identified and addressed [15]. Against this background the patient was assured, on the basis of evidence, that a good outcome was highly likely. They were encouraged to remain at work [15]. If the patient rated their pain as moderate or severe, analgesics were provided, in the form of paracetamol, on a time-contingent basis. All patients were instructed in a set of simple stretching exercises (as illustrated in the book of McKenzie [16]). A typical first consultation took 50 min.
If the worker alleged any occupational safety issues at their worksite, these were assessed. If advocacy was required, the staff specialist either visited the worksite, immediately after the first consultation, to discuss the reported injury with the worker's immediate supervisor or requested that the supervisor meet with the staff specialist and the patient at the consulting room to discuss any concerns and to implement any modifications or rectifications that were required [17,18]. Such interventions included, for example, the accelerated delivery of overdue lifting devices, or reminders of prescribed lifting practices.
Patients were scheduled for a follow-up consultation within 1 week of first being seen. At this consultation, their understanding of information provided at the first consultation was checked. Instructions and explanations were repeated, or reinforced, as necessary. Compliance with the use of exercises was checked, as was the patient's return to work. A typical second consultation took 
25 min.
If indicated, patients were returned to modified duties, in consultation with the worker's supervisor. However, when modified duties were prescribed, the patient's progress was monitored, at least weekly, with the objective of returning the worker to full duties as soon as they were capable.
Those patients who elected to consult their own practitioner underwent whatever intervention their practitioner prescribed. They were entitled to time off work, or modified duties, if their practitioner so certified.
In accordance with the workers' compensation legislation, administrative staff routinely and prospectively maintained injury management records of all patients. These staffs were neither involved in nor aware of the study. At no time were patients told that they were part of a study, for indeed, no formal study was conducted, in which the patients were in any way artificially manipulated.
The study consisted of an audit of the records of all workers who registered an incident. From the records, the investigator harvested and tabulated data with respect to return to work immediately, return to modified duties, duration on modified duties, recovery, recurrence and development of chronic low back pain. Recovery was defined as complete resolution of symptoms, or sufficient resolution to enable full return to work and requiring no medical care. Chronicity was defined as persistence of pain beyond 3 months. The numbers in each category were tabulated and proportions were calculated. Proportions were compared using 95% confidence intervals.
Ethics clearance was not sought because we felt that the study constituted a quality assurance audit and did not involve any experimental intervention.
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Results |
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The study population consisted of 253 consecutive workers who reported a low back injury during the period 1 January 2000 to 30 June 2003. Of these workers, 62 elected to pursue medical care privately. The remaining 191 (75%) consulted the staff specialist. Of these, 27 (14%) elected to pursue care privately, after the initial consultation with the staff specialist. One hundred and sixty-four patients (65% of the total population) remained under the care of the staff specialist.
The three treatment groups were similar with respect to age, gender and vocational class (Table 1). However, technical staff and female service staff (laundry and kitchen) made up greater proportions of the group who elected to pursue private care from the start. All the workers who transferred from evidence-based care to usual care were females, but statistically their numbers were not disproportionate to the numbers of females in other groups. In other respects, they did not differ demographically from those who remained under evidence-based care.
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Under evidence-based care, all patients complied with the elements prescribed, for their particular circumstances, from the core program of management. Under usual care, management consisted of certification for modified duties or time off work, variously coupled with analgesics and physiotherapy. No patient was prescribed opioids under usual care.
The outcomes of patients who remained under evidence-based care were consistently better than those who underwent usual care (Table 2). Of those patients who persisted with evidence-based care, 63% returned immediately to normal duties, only 37% required modified duties, only one lost time off work, 98% recovered and only 10 (6%) suffered a recurrence. In contrast, no patient under usual care resumed normal duties immediately, 92% were given modified duties, 35% were certified by their general practitioner for time off work and although 84% recovered, 27% suffered a recurrence. The corresponding figures for those patients who transferred to usual care, after declining evidence-based care, were similar to those who elected to pursue usual care from the start, and were all significantly different from those of patients who remained under usual care. The number of patients who developed chronic pain was small in all groups; the proportions were greater in the usual care groups, but were significantly greater only at the 89% confidence level.
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When prescribed modified duties, 70% of patients under evidence-based care spent <2 weeks on those duties before successfully resuming normal duties (Table 3). Reciprocally greater proportions of patients under usual care spent longer periods on modified duties (Table 2). The differences in proportions are not significant at the 95% level, but are significant at the 92% confidence level.
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In the course of the study, three types of patients were identified among those who presented to the staff specialist. There were 61 who presented with no psychosocial issues and accepted evidence-based care readily. Another 46 patients spontaneously expressed various beliefs, during the consultation, about how their back pain might be managed. These beliefs were based on past learning, word of mouth or recent visits to Internet sites that were often not evidence-based. Of this group, 32 complied with evidence-based care after discussing their beliefs with the staff specialist, and having the concept of evidence-based care explained to them. The remaining 14 transferred to usual care.
The third group were 84 patients who credibly did have back pain, but their alleged disability was dissonant with the history of injury. Exploring psychosocial factors, such as beliefs about work and attitudes toward it, typically revealed a problem, such as job dissatisfaction or dislike of their supervisor [15,19]. Thirteen of this group transferred to usual care, but 71 remained under evidence-based care. In addition to the core program of management, these patients required one or more consultations over which the psychosocial issues affecting them were addressed. These issues were managed with concerted enquiry, understanding, explanation and advice [15]. If worksite intervention was indicated, the staff specialist acted as the patient's advocate to address with the worker's supervisor any perceived problems [15,18]. Although these patients required longer consultations or a greater number of consultations than usual, their outcomes were nevertheless favorable, and did not differ statistically from those of the other patients who pursued evidence-based care.
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Discussion |
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When offered the choice between usual care and prompt care at the worksite, 71% of workers with acute back pain elected to avail themselves of in-house care. When exposed to evidence-based care, only 14% declined and transferred to usual care. These figures provide encouragement to proponents of instituting evidence-based practice for workers' compensation patients. The majority of workers found evidence-based care acceptable and complied with it. Office staff, nursing and other clinical staff were more likely to accept evidence-based care. Technical staff and service staff were more likely to elect to pursue usual care, but nevertheless, the majority of these accepted evidence-based care when exposed to it.
Return to normal duties, lost time, recovery and recurrence are outcome measures relevant to workers, employers and insurers alike. In these domains, the present audit found that workers under evidence-based care achieved outcomes that were statistically and clinically better than those achieved under usual care.
Prompt return to work was achieved in the majority of cases under evidence-based care, and was associated with a high rate of full recovery and low rates of recurrence and chronicity. Under usual care, greater proportions of workers lost time off work and spent more time on modified duties, yet had lower rates of recovery and higher rates of recurrence and chronicity.
Retrospectively, three types of patients were identified: those who accepted evidence-based care readily (32%), those who brought to the consultation beliefs about how their back pain should be managed (24%) and workers with job dissatisfaction and psychosocial difficulties in the workplace (44%). The majority of patients, who volunteered beliefs about their management, accepted the principle of evidence-based care once it was explained to them. Patients with psychosocial problems had longer periods of care, in order to resolve those problems, but ultimately did not exhibit worse outcomes than others under evidence-based care.
The cardinal weakness of the present study was that patients were not randomized. Consequently, the outcomes in favor of evidence-based care cannot be definitively attributed to the precepts of evidence-based care. In contrast, however, the present study avoided the possible confounders of randomized studies. Since the workers did not know that their outcomes were being studied, they were not subject to nocebo effects, halo effects, dissatisfaction with being randomized to the wrong group and reporting bias. The data obtained describe the natural behavior of injured workers and their outcomes, free of the influences of allocation and the effects of eliciting outcomes.
For those who intent upon conducting randomized trials of evidence-based care, these data provide several salutary warnings. There will be workers who would prefer usual care. Others will find evidence-based care unpalatable. Both of these factors could prompt nocebo effects if such patients are allocated to an unappealing treatment. Furthermore, workers in different vocational classes differ in accepting evidence-based care or preferring usual care.
The results of the present study echo those of the previous study in which evidence-based care was provided to patients who were not subject to workers' compensation claims [11]. In so doing, the present study shows that the principles of evidence-based care can be successfully applied in a workers' compensation setting.
The results also echo those of another study [20], in which the intervention was a light mobilization program based on that of Indahl [21]. The guidelines used in the present study were also based on the principles espoused by Indahl [21]. Both studies showed reduced sick leave, compared to usual care, but the distinction was that the present study addressed acute low back pain, within 48 h of onset, as opposed to subacute pain, which had been present for 8–12 weeks.
A comparison of relevance to occupational physicians is with the study of Loisel et al. [17]. They showed that occupational intervention coupled with clinical intervention was more effective than either intervention alone. For this reason, worksite intervention was adopted as a critical component of management, when indicated. That intervention is not limited to ergonomic and safety issues but, in the experience of the present study, extends to resolving psychosocial issues in the workplace.
The present study shows that evidence-based care can be accepted by the majority of injured workers and leads to successful outcomes. Such care does not require specialized skills in traditional medical terms. Guidelines for the management of acute back pain abjure manual therapy, special exercises, injections or potent drugs [7]. They emphasize explanation, reassurance and helping the patient to resume normal activities, including work. However, evidence-based care is not trivial, simplistic or dismissive. It requires conscientious, concerted, credible and convincing care [15]. Moreover, practitioners need to be able to adapt their management to various types of patients. For patients with informed, but mistaken, beliefs about their management, practitioners need to be aware of the literature and be able to explain convincingly why the patient's evidence is wrong and why alternatives are preferable. For patients with psychosocial and occupational issues, practitioners need to be able to elicit these and deal with them [15,19].
An intriguing question that arises from the present study is why usual care emerged as less effective, even when patients elected to pursue that form of care. These patients did not appear to be clinically different from those who pursued evidence-based care. The fact that none required opioids indicates that their pain was not more severe than average. The fact that most eventually returned to work indicates that they were not more severely injured.
Possible explanations are that general practitioners do not practice according to guidelines, and are more accommodating to their workers' compensation patients. According to guidelines [8,9,10], time off work is not indicated as a primary intervention for most cases. Yet it was liberally used in usual care, in the present study. Moreover, once used, it tended to be used for longer than appeared necessary. In contrast, under evidence-based care, patients accepted the merit of returning to work, once it was explained to them. In that regard, return to work was not an administrative action; it was prescribed for medical reasons, on the basis of evidence. The contrast with usual care suggests the suspicion that it is easier to give a patient a certificate than to spend the time explaining why they do not need one. Similarly, patients might prefer usual care if their practitioner does not explore psychosocial issues and, instead, simply accommodates their request for a certificate.
Such negative influences do not apply if a practitioner conscientiously practices according to the guidelines. Whether general practitioners can afford the time to practice in this way becomes a critical issue both for the practitioners and those who administer workers' compensation systems. As demonstrated in the present study, there appears to be merit in having dedicated physicians, trained in evidence-based practice, who can see workers promptly and as often as is necessary, for as long as necessary.
Based on the present data, future studies might care to focus on what appear to be the pivotal issues. Evidence-based care needs to be adaptable, to accommodate patients with different beliefs and with different profiles of problems. The possible effects of the attitude and personality of the practitioner, as opposed to the elements of evidence-based care, need to be considered. The significance of prompt and expert worksite intervention should be quantified. The sources of patient dissatisfaction with evidence-based care should be explored. Perhaps most vitally, methods should be tested whereby practitioners in usual care might better comply with the principles and elements of evidence-based care.
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Conflicts of interest |
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None declared.
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References |
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- Agency for Health Care Policy and Research. (1994) Acute Low Back Pain in Adults: Assessment and Treatment(US Department of Health and Human Services, Rockville, MD).
- American Academy of Orthopaedic Surgeons. Evidence-based recommendations for patients with acute activity intolerance due to low back symptoms. Orthop Update (1995) 5: pp. 625–632.
- . (1995) National Advisory Committee on Core health and Disability Services, Accident Rehabilitation and Compensation Insurance Corporation. Clinical Practice Guidelines. Acute Low Back Problems in Adults: Assessment and Treatment(Core Services Committee, Ministry of Health, Wellington, New Zealand).
- Dutch College of General Practitioners (NHG). Practice Guideline Low Back Pain (1996) (Nederlands Huisartsen Genootschap, Utrecht, The Netherlands).
- Royal College of General Practitioners, Chartered Society of Physiotherapy, Osteopathic Association of Great Britain, British Chiropractic Association, National Back Pain Association. Clinical Guidelines for the Management of Acute Low Back Pain (1996) (Royal College of General Practitioners, London, UK).
- Koes BW, can Tulder M, Ostelo R, Burton AK, Waddell G. (2001) Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 26:2504–2513.[CrossRef][Web of Science][Medline]
- AustralianAcute Musculoskeletal Pain Guidelines Group. Evidence-Based Management of Acute Musculoskeletal Pain (2003) (Australian Academic Press, Brisbane, Australia) http://www.nhmrc.gov.au (27 September 2006, date last accessed).
- In Carter JT and Birrell LN (Eds.). Occupational Health Guidelines for the Management of Low Back Pain at Work—Principal Recommendations (2000) (Faculty of Occupational Medicine, London, UK).
- Waddell G and Burton AK. (2001) Occupational health guidelines for the management of low back pain at work: evidence review. Occup Med (Lond) 51:124–135.
- Staal JB, Hlobil H, van Tulder MW, et al. (2003) Occupational health guidelines for the management of low back pain: an international comparison. Occup Environ Med 60:618–626.
[Abstract/Free Full Text] - McGuirk B, King W, Govind J, Lowry J, Bogduk N. (2001) The safety, efficacy, and cost-effectiveness of evidence-based guidelines for the management of acute low back pain in primary care. Spine 26:2615–2622.[CrossRef][Web of Science][Medline]
- Bogduk N and McGuirk B. (2002) Medical Management of Acute and Chronic Low Back Pain. An Evidence-Based Approach(Elsevier, Amsterdam, The Netherlands).
- Bogduk N and McGuirk B. (2002) History. In Bogduk N and McGuirk B (Eds.). Medical Management of Acute and Chronic Low Back Pain. An Evidence-Based Approach(Elsevier, Amsterdam, The Netherlands) pp. 27–40.
- Bogduk N and McGuirk B. (2002) Natural history. In Bogduk N and McGuirk B (Eds.). Medical Management of Acute and Chronic Low Back Pain. An Evidence-Based Approach(Elsevier, Amsterdam, The Netherlands) pp. 15–17.
- Bogduk N and McGuirk B. (2002) Algorithm for acute low back pain. In Bogduk N and McGuirk B (Eds.). Medical Management of Acute and Chronic Low Back Pain. An Evidence-Based Approach(Elsevier, Amsterdam, The Netherlands) pp. 71–81.
- McKenzie R. (1997) Treat Your Own Back 5th edn (Spinal Publications, Lower Hutt, New Zealand).
- Loisel P, Abenhaim L, Durand P, et al. (1997) A population-based, randomized clinical trial on back pain management. Spine 22:2911–2918.[CrossRef][Web of Science][Medline]
- Bogduk N and McGuirk B. Bogduk N and McGuirk B. (2002) The evidence. Medical Management of Acute and Chronic Low Back Pain. An Evidence-Based Approach(Elsevier, Amsterdam, The Netherlands) pp. 83–112.
- Bogduk N and McGuirk B. (2002) Psychosocial assessment. In Bogduk N and McGuirk B (Eds.). Medical Management of Acute and Chronic Low Back Pain. An Evidence-Based Approach(Elsevier, Amsterdam, The Netherlands) pp. 69–72.
- Hagen EM, Eriksen HR, Ursin H. (2000) Does early intervention with a light mobilization program reduce long-term sick leave for low back pain? Spine 25:1973–1976.[CrossRef][Web of Science][Medline]
- Indahl A, Velund L, Reikeraas O. (1995) Good prognosis for low back pain when left untampered: a randomized clinical trial. Spine 20:473–477.[Web of Science][Medline]
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