Tag Archives: lower back pain

How to Help Workers With Low Back Pain

Once an injured worker has low back pain, chances are pretty good he’ll have a recurrence. In fact, new research shows that after an acute episode of LBP, one-third of people will have another episode within a year; and the odds of a recurrence triples after two episodes.

Those statistics are somewhat surprising, given that recurring LBP can be avoided. Gustavo C. Machado and his colleagues at the University of Sydney’s School of Public Health tracked more than 1,000 LBP patients in Australia from 2011-12. Their results were published by the American Physical Therapy Association.

“We know if you do exercise and receive advice you reduce the risk of having a recurrence,” said Machado, lead author of the study. “Some research shows if you do exercise, you reduce your risk of a back pain episode by 35%; and if you do exercise and get some sort of education or information, that risk is reduced by 45%. So it’s a big reduction in risk. “

With LBP one of the most prevalent causes of workers’ compensation claims, the industry could prevent unnecessary pain among workers and save significant dollars for payers by better educating workers on LBP.

LBP

An estimated one-third of workers’ compensation claims involve LBP, with direct costs of more than $14 billion annually. Some 1 in 4 workers with LBP remain out of work for up to six months, increasing the chances of permanent disability.

Workers of any age can experience LBP, though it typically affects those over the age of 40. The reasons for LBP can vary with age.

“With older workers, you see degenerative changes,” said Daniel Sanchez, a physical therapist and VP of Operations for OnSite-Physio, a company that provides PT to injured workers on site. “For younger workers, the LBP tends to be muscular soft tissue in nature. But both degenerative and soft tissue LBP can be recurring.”

See also: The State of Workers’ Compensation  

Acute episodes of LBP last for no more than six weeks, while chronic LBP continues for at least three months. While injured workers with acute LBP should avoid vigorous activity, that does not mean they should be bedridden.

“The first thing initially is to rest, but don’t over rest,” Sanchez explained. “Depending on the severity, maybe a day or two of not overdoing it, but not being laid out in bed all day. Just not doing heavy exercise; no movements that aggravate the pain.”

The simple act of reaching down to pick up something can aggravate the pain. For the first couple of days, injured workers should “take it easy, allowing the body to heal,” Sanchez said.

Machado concurred. “For those patients, the best thing is to remain active. So do not stay in bed, just keep on the move. Try to keep up with routine activities, such as work,” he said. “It’s also very important to receive advice and education about pain, about recurrences.”

The majority of LBP cases resolve within a few weeks. For those that linger, a different regimen is needed.

“A quick fix for LBP does not exist,” Machado said. “The latest research shows taking pills doesn’t help much. Exercise and education seem to be the key for treating back pain, reducing back pain and preventing recurrences. The problem is people are not engaged in exercise.”

Exercises

There are a variety of exercises touted as best for addressing back pain: pilates, yoga and strengthening among others. They are equally effective.

“The more research that comes out, the more it’s clear there is no one exercise that is better,” Machado said. “The best is the one you like to do, they one you’re going to engage in, the one you’re going to stick to.”

A combination of exercises that improve stability, flexibility and strength will increase mobility and range of motion, thereby reducing pain. When muscles are tight and weak, the joints cannot move properly, Sanchez said.

  • Strengthening exercises. The most effective of these, according to Sanchez, are those that target the muscles in the front and back of the spine; the deeper, transverse abdominis that support the spine. Planks are among the most effective and can help the intrinsic, tiny muscles that attach to each vertebrae. These provide postural support which is very important.
  • Flexibility exercises. These, especially to the lower extremities, are extremely important. The lumbopelvic hip complex includes muscles that attach from the lower extremities, such as the hip rotators, hamstrings and hip flexors. Exercises that target these areas can relieve tight hips, which helps relieve chronic LBP.
  • Posture. Practicing sound posture, good body mechanics and lifting habits are also helpful, Sanchez said. Having a neutral spine is the goal.

Future of LBP

The research on LBP should include more robust studies looking at recurrence, Machado said. In the meantime, he and his colleagues are analyzing other aspects of LBP.

“The main one we are looking at is over diagnosis and treatment, because a main issue is that people get lots of X-rays and imaging and that’s usually unnecessary,” Machado said. “Lots of people also get opioids. We know that’s a big problem, especially in the U.S. It is not helpful. There are few benefits and really serious risks for side effects.”

Machado has a trial study starting soon in Sydney. Along with others, he is also looking into technology; specifically, smart phone apps that claim to help back pain.

See also: 25 Axioms Of Medical Care In The Workers Compensation System  

“We found over 69 apps to download. They’re making big promises but have not been tested for effectiveness,” he said. “We are planning to do another study in a few months on a specific app that could be promising… This one recommends a 10-week exercise program, mainly strengthening. The problem is there is no research testing this app as to whether it’s effective in reducing pain.”

For now, Machado hopes the latest study will provide guidance for providers treating patients with LBP. “We didn’t know how common recurrence was; it shows one-third after recovery will have another episode,” he said. “That’s something a clinician can use to educate a patient when they come, to say ‘look, a third of people have a recurrence, so engage in exercise.’ They can use this to educate them now.”

For more information visit https://www.apta.org or http://www.onsite-physio.com.

Better Way to Handle Soft-Tissue Injuries

The most costly problem facing employers today is work-related, soft-tissue injuries, more commonly known as work-related musculoskeletal disorders (WRMSD). According to OSHA, WRMSD account for 34% of lost work days in the U.S., as well as a third of the dollars spent in workers’ compensation and of all work-related injury cases.

Not surprisingly, soft tissue injuries — to the ligaments, tendons and fibers of the body that connect the bones — are difficult to diagnose. Standard diagnostic tests such as X-rays or imaging are frequently unable to document the presence of pain and loss of function. As a result, diagnoses are often subjective, leading to poor treatment (including unnecessary surgery and overuse of narcotics), extra lost work time, precariously high medical costs and, at times, fraudulent claims.

There is a need for accurate, timely and evidence-based diagnosis and treatment to curtail escalating costs and improve clinical outcomes, as these case studies show:

Case 1

A 44-year-old gentleman had undergone a baseline EFA. (The Electrodiagnostic Functional Assessment, or EFA, combines mutltichannel wireless electromyography (EMG) with range-of-motion testing and integrates that with a functional output). He is employed as an unloader in the shipping department. He alleged a work-related injury in October 2014, five weeks into his employment. He stated that he injured his shoulders when he put his hands out to block a fall. He complained of bilateral shoulder pain, radiating to the right upper extremity. He rated the pain as an eight on a scale of one to 10. But an EFA found no change from the baseline test.

Outcome: Because there was no change from his baseline, he was released from treatment and advised to see his primary care physician for any further medical needs.

Case 2

A 37-year-old gentleman was employed as a loader. He alleged a work injury in October 2014; when he bent to lift some ice, he felt a pain in his lower back. He complained of radiating lower back pain, into the left lower extremity, rated as a 6/10. He was referred by his occupational medicine doctor, as there were no objective findings, and his subjective complaints seemed out of proportion. An EFA revealed normal EMG activity, with chronic, unrelated pathology.

Outcome: When he returned for his follow-up evaluation after the EFA, he still had the same subjective complaints. After his doctor reviewed the EFA findings, he stated that he felt much better and asked for a release to return to  full duty at work.

Case 3

A 34-year-old gentleman was employed as a mix/truck driver. He had undergone a baseline EFA in June 2014 and had a work-related motor vehicle accident in September 2014. His head struck the roof of his truck, and he was not wearing a hard hat. He complained of neck, shoulder and head pain. When an EFA was compared with the baseline, chronic, unrelated pathology was noted. However, the comparison also revealed a change in the paracervical region. This change was consistent with the date and mechanism of injury and with his subjective complaints.

Outcome: The EFA comparison was able to identify and redirect care, away from the chiropractic care that he was receiving. After imaging studies were performed and the results found to be consistent with the EFA findings, he received site-specific, conservative care for his work-related injury, and his symptoms improved.

It is our opinion that the EFA-STM provides a book end solution, comparing a pre-injury test to a post-injury assessment to objectively and accurately determine AOECOE (arising out of employment/course of employment) status. One must base a medical evaluation on facts, not subjective complaints. When that is accomplished, proper diagnosis and treatment are rendered, and outcomes improved.

The authors invite you to join them at the NexGen Workers’ Compensation Summit 2015, to be held Jan. 13 in Carlsbad, CA. The conference, hosted by Emerge Diagnostics, is dedicated to past lessons from, the current status of and the future for workers’ compensation. The conference is an opportunity for companies to network and learn, as well as contribute personal experience to the general knowledge base for workers’ compensation. Six CEU credits are offered. For more information, click here.

MRIs: Part of the Solution, or Problem?

Another study sponsored by Liberty Mutual concludes that early magnetic resonance imaging for diagnosis of back pain leads to higher costs and poorer outcomes.

The study, published in the August issue of the medical journal Spine, showed that when back pain patients went through MRI scans within the first month after injury, they were between 18 to 55 times as likely as the reference group to receive more diagnostic and invasive procedures.

Glenn Pransky, a co-author of the study and director of the Liberty Mutual Center for Disability Research, said that MRIs can put patients in a mindset of trying to find a specific problem in their back and then seeking to fix it.

“People get hung up on thinking, ‘Oh, I’ve got this ruptured disc. That must be the problem. I won’t be well until somebody fixes that ruptured disc,’” Pransky said.

As many of us know, herniated discs and other spinal “abnormalities” are actually quite common.

Pain is complex, and the cause of pain is often illusive.

In an Aug. 20 webinar from managed care company Paradigm Outcomes, two physicians pointed out that pain can come from many places.

“When you look at somebody’s pain, they have the pain sensation — there could be nerve pain, there could be soft tissue-muscle-tendon pain,” said Steven Moskowitz, senior medical director of Paradigm’s pain program. “They could have pain because they’re deconditioned and out of shape and stiff, and so it hurts to be stiff and to move when you’re stiff. And then they can have. . .  emotional components.”

Bowzer’s pain started bending over for his cigar.

 

In his most recent book, Living Abled and Healthy, Christopher Brigham, MD, no stranger to workers’ compensation and lead editor to the AMA 6th Ed. Guide for Rating Permanent Disability, examines people who have had catastrophic injuries or who grew up “less than able” but overcame these difficulties, and compares them with folks who can’t seem to surmount such obstacles.

[Disclosure — Brigham is a friend, and I contributed a small part to the book.]

Brigham argues that our mind-body connections are surprisingly strong and that people in general discount the effect our emotions, psychology, feelings and perceptions have on our physical being.

“If we believe something is helping us we will likely feel better,” Brigham says. “If we believe something is hurting us, we will likely feel worse. Our attitudes define who we are, and the choices we make determine our destinies.”

Robert Aurbach, an attorney, researcher and international workers’ comp expert now consulting in Australia, has noted that neuroplasticity — the brain’s ability to reorganize itself by forming new neural connections — can play a big role in one’s perception of ability versus disability.

Essentially, continued “training” to be disabled, rather than abled, forms neural connections that reinforce negative associations with pain.

The extent to which early MRIs contribute to the perception and emotion of disability has yet to be fully quantified, but the Liberty Mutual study suggests the connection it is not insignificant.

According to a 2013 report from the Bureau of Labor Statistics, sprains, strains and tears made up 38% of work-related injuries in 2012, making those the most common source of claims. In that category, the back was the most-often injured body part, making up 36% of sprains, strains and tears.

Essentially that means that 1/6th of all work injury claims are related to back pain. How many of those end up worse because of diagnosis and treatment fostered by early MRI findings and might have otherwise been adequately (and perhaps more effectively and efficiently) treated conservatively isn’t known, but I suspect the number is considerable.

The authors of the Liberty Mutual study found that MRI use for patients with lower back pain wasn’t distributed evenly across the U.S., and they hope to continue the study to determine whether certain states are more prone to improper use of the scans.

I think it would also be interesting and beneficial to correlate that study with information about disability rates; my guess is that we (the grand collective “we”) make people more disabled than they otherwise would be in our zeal to use medical technology and attempt to find easy answers to complex problems, like pain and disability.