For employers, the problem of staff with chronic back pain won’t go away. Occupational health provides an essential service in checking on the basic working environment, looking at lighting and layouts, equipping staff with ergonomic chairs and foot support, keyboards and mice, delivering all the training that’s needed to minimise risks from any kind of physical activity in the workplace, whether it’s lifting, standing or days of sitting in front of a screen. In healthcare there’s more awareness of the effects of musculoskeletal disorders (MSDs) in general among GPs and treatments have also become more sophisticated, with growing use of spinal imaging, spinal injections, spinal fusion surgery and stronger pain relief drugs.
The correlation between back problems and lower levels of absence
Of the 131 million days of sickness absence in the UK (according to the most recent study carried out by the Office for National Statistics in in 2013), 31 million were for back and neck pain – more than any other reason given. High levels of cases progress from being a single, acute incident into a long-term issue. Figures suggest that around three to 10 percent of cases of lower back pain, for example, become chronic. Up to around 62 percent of people still experience the pain after one year. The sheer level of absence, as well as the potentially crippling impact of back pain on people’s lives outside of work, means that MSDs have a huge financial and social cost.
Getting the intervention right with staff already reporting a chronic problem is critical. Some employers take a straightforward approach that provides clarity for both sides by fast-tracking to physiotherapy. Employees with a record of absence with MSDs are invited to undertake a functional assessment to identify what the employee is physically capable of doing. The results are then used to tailor workplace adjustments and provide physiotherapy to keep employees affected by physical problems healthy and working for as long as possible.
Psychology and pain
Increasingly, health professionals are moving to a position that says that psychology plays a significant role in conditions like chronic back pain. This isn’t only an anatomical or physiological problem. Physiotherapy and surgery isn’t necessarily going to be enough – an issue which has been long understood by osteopaths, who think more holistically about the root causes of physical disorders. GPs have tended to use a ‘red flag’ system with MSDs, where they will examine patients to rule out potential physical causes of back pain, such as inflammation, infection, disc problems, trauma and cancer. These are rare, but can be ruled out as more easily identifiable causes. Some GPs are starting to also use a ‘yellow flag’ to explore where there might a clear underlying problem, such as a psychological issue.
The yellow flag approach is starting to be made available to employers through what’s become known as the Orebro Musculoskeletal Pain questionnaire. This covers five relevant areas: function, pain, psychological, fear-avoidance and miscellaneous.
There are 25 standard questions, mostly on a zero to 10 scale, which explore individual attitudes and feelings about levels of pain experienced, its effect on their ability to work, experiences of anxiety or depression and any impact on sleep. It has been found to be effective in predicting future issues where back pain could become chronic and affect their ability to work. In other words, this kind of ‘biopsychosocial’ approach picks up on negative attitudes, fears and concerns that exacerbate and encourage the experience of chronic pain. It may be an existing psychological problem; anxiety, depression or the tendency to have an exaggerated sense of, or response to, pain, or there might be issues relating to the heavy demands of work or problems with the work environment itself.
Using data from the Orebro questionnaire is a basis for referring employees to other forms of support that tackle the underlying root causes – often through Cognitive Behavioural Therapy, which is effective at encouraging more positive attitudes and therefore a better ability to cope with the types of pain associated with MSDs. One research study looked at the impact of a number of programmes offering a combination of physical therapy along with psychological therapy.
The progress of chronic back pain sufferers was tracked over at least a year, showing that including a psychological element of treatment was more likely to lead to a better recovery than exercise alone. There’s also good evidence from a programme undertaken in New South Wales, Australia under it’s Work Cover initiative which saw successful results in terms of helping speed up recovery times and help more people back to work. Orebro is now being used by Bluecrest Wellness in the UK as part of a standard health screening process, where organisations are providing screens across whole staff populations.
The scale of the back pain issues for employees and employers means new thinking and approaches are needed. Getting the work environment and facilities right is an important basis, it ticks the box and demonstrates a commitment to support, but clearly doesn’t remove the back problems issue. The more we can break out of the standard routines of treatment and understand the whole picture, the closer we’ll come to helping people stay in work, avoiding what can become a vicious circle of physical and mental illness.
Dr Nick Summerton is medical director at Bluecrest Wellness, a general practitioner and public health physician with particular interests in diagnostics and screening. Nick is a member of the Royal College of General Practitioners, a fellow of the Faculty of Public Health and has been awarded a doctorate from the University of Oxford for original work on primary care diagnostics.
