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first_imgBack problems have a nasty tendency to become chronic and the outcome isheavily dependent on the attitude of the patient and the healthcareprofessional. Unhelpful beliefs must be challenged and individuals involved intheir own recovery programme, by Dr Grahame Brown Disability attributable to back pain in people of working age is one of themost spectacular failures of modern health care in the industrialised world.Its greatest impact is on the lives and families of those affected. However, italso has a major effect on industry through absenteeism and avoidable costs, onsocial security costs and on pension schemes. This article looks at ways inwhich health care professionals can reduce the risk of adding to this massivepersonal, social and economic burden when individuals present with thecomplaint of back pain. All healthcare professionals involved in managing people with back pain mustbe familiar with a paradigm shift in thinking about this problem with thepublication of Waddell’s The Back Pain Revolution.1 However, attitudes, beliefsand behaviour must change in healthcare professionals as well as patients, andfrequently it is the former who are more resistant to change. A recent evidence review from the Faculty of Occupational Medicine, London2highlights our current state of knowledge and makes recommendations that areessential reading for any OH professional. It is clear that attempts over the past few decades (supported bylegislation) to prevent back pain occurring in the workplace (primaryprevention) have been unsuccessful. These methods have been largely based onthe injury model of back pain (for example, manual-handling training) andconcentrate on the orthodox, disease model of medicine. The only evidence todate that activity in the workplace aimed at primary prevention has had anyeffect on outcomes that matter to individuals and employers is the promulgationof information that challenges attitudes and beliefs based on acognitive-behavioural model.3-5 At present, these methods, and secondary andtertiary prevention strategies, provide the most effective means of reducingthe risk of costly chronicity and disability. Treatment aims The goals are to prevent disability and chronicity developing. OccupationalHealth professionals are in an ideal position to see workers who are havingdifficulty with back pain early in the course of events and to influencepositively the outcome. The first consultation a person troubled by back pain has with a health careprofessional is probably the most important. It will either set that person onthe road to recovery and restoration of function or, as happens all too often,it will precipitate despair, depression and disability. So, at this importantstage, it is helpful for the health care professional to have in mind a fewimportant facts and questions: – The complaint of back pain affects everyone at some time, with 90 per centof us experiencing significant interference with daily activities for at least48 hours at some time in our lives. And 40 per cent will experience recurringproblems with our backs – Psychosocial factors may operate at different stages in the developmentand perpetuation of low back pain. These factors may have precipitated thefirst consultation for the complaint. Often, unfortunately, causation iswrongly attributed to what the person was physically doing when firstcomplaining of symptoms. It is important to know the risk factors forchronicity and disability – Make an initial assessment of the clinical problem: Is it ‘simple back pain’,nerve root pain or is there possible serious pathology? If there are anysymptoms that give cause for alarm, for example, age of onset less than 20 orgreater than 55 years, or the presence of constant progressive pain, thepatient should be referred promptly to a surgeon. Referring a patient willensure laboratory tests, including full blood count, sedimentation rate andbiochemistry screen are performed to rule out occult pathology – Ask yourself the question: “What can I do right now to reduce the riskof this person becoming disabled or a chronic sufferer?” Most often thiswill not involve skilled physical treatments but will be achieved by reducinganxiety and emotional arousal, challenging unhelpful attitudes and beliefs,providing positive information and involving individuals in their own recoveryprogramme. Giving the person a copy of The Back Book4 to read is likely to bevery effective The interview with the patient is vitally important. Remember threefunctions of the medical interview: – Establish rapport: Greet the patient warmly and by name. Listen activelyand reflectively. Detect and respond to emotional cues – Collect data: Do not interrupt the patient. Use open questions first andcollect accurate information with closed questions later. Elicit patient’sexplanatory model. Develop a shared understanding – Negotiate and agree a management plan. Provide information. Usereassurance appropriately. Make links. Negotiate behaviour change An interview conducted in this way can be very therapeutic in itself. Thisperson-centred (as compared with a purely disease-based) approach improvesoutcomes that matter to patients, shortens follow up and reduces unnecessaryinvestigations. Physical treatments OH departments do not normally provide physical treatment services, but someuse in-house physiotherapists, or osteopaths. It is important to target thisservice where it is most likely to be effective for the patient andeconomically viable for the organisation. For example, after 12 weeks’ sickness absence, figures show that 25 per centof workers with low back pain will never return and this figure increases to 50per cent by 26 weeks off. When the goal is to reduce long-term sickness absence, it therefore appearsthat the group of workers to whom available resources are best targeted arethose who are off work for between four and 12 weeks. Interventions provided tothose who are at work but struggling are arguably no less important to helpthem remain functioning. Those at work and coping with nuisance symptoms notinterfering with their ability to work are a low priority. Some form ofpriority has to be given when resources are insufficient to meet demand. Whatever the course of treatment for low back pain, or any other regionalpain problem, it is worth remembering that if it is not beginning to make anyuseful difference to the patient, as shown by improved function, by, at themost, six treatments, it is not working. Reassess, review the obstacles torecovery and do something different. Prolonging ineffective treatments is verydamaging to the psychological well-being of the patient. Much can be done and begins at the first consultation. Some important pointsare: – Encourage a return to work as soon as possible; there is no need to waituntil all the pain has gone – Make a return to normal work the goal: this reinforces the belief in thepatient that normality can be achieved. It also, and vitally, reducesfear-avoidance beliefs and behaviour – Use a fixed period for return to work, with a gradual increase in activityand responsibility to help achieve a return to normal activities. This must betime-limited, with goals set and reviews arranged. Some form of temporaryrestrictions may be helpful, but must be time-limited. It is a mistake to allowrestrictions to depend on ‘how the patient feels’: this encourages pain andillness behaviour and only creates more problems in the future, which are evenmore difficult to solve – Use treatments that facilitate active rehabilitation and that do notinterfere with it – Consider short spells in functional restoration programmes for those whohave demonstrated a commitment to work hard to improve their functionalcapacity, but are having difficulty. These excellent (but expensive) programmesshould not be used, however, in the hope that they can magically motivate aperson who has learned helplessness, is depressed, is focused on compensationissues of whatever nature or who has no belief that their quality of life oroccupational status can be improved – Support and encourage the person through the difficulties and setbacksthat will inevitably occur. OH professionals are in an ideal position to dothis – Consider redeployment or severance only when all reasonable attempts havebeen made to rehabilitate to normal work. Healthcare professionals not trainedin OH frequently advise patients, who mention during a consultation that theyare experiencing difficulties at work with back pain, to give up or findalternative work. The consequences are not discussed and are often devastatingto the individual, especially those with limited transferable skills – Liaise with all health care professionals involved in the case. Beprepared to take a lead in case management. Seek other opinions if you believe thepatient will benefit Summary The causes of low back pain are multifactoral, and management is multimodal.Psychosocial factors strongly influence presentation and outcome at all stagesand are no less important, even in the presence of clearly identifiable spinalpathology. These psychosocial factors, particularly, are amenable to intervention inthe occupational setting. Excellent communication and consulting skills must bea goal for all healthcare professionals. Learning the skills of brief, solution-focusedcounselling will improve your outcomes and job satisfaction. References 1. Waddell G (1998) The Back Pain Revolution. Churchill Livingstone, London 2. Occupational Health Guidelines for the Management of Low Back Pain atWork: Evidence review and recommendations. (2000) Faculty of OccupationalMedicine, London. 3. Buchbinder R, Jolley D, Wyatt M (2001) Population-based intervention tochange back pain beliefs and disability: Three part evaluation. BMJ,322:1516-1520. 4. Symonds TL, Burton AK, Tillotson KM, Main CJ (1995) Absence resultingfrom low back trouble can be reduced by psychosocial interventions at theworkplace. Spine, 20: 2738-2745. 5. Roland M, Waddell G, Moffett JK, Burton AK, Main CJ, Cantrell E, (1997)The Back Book. The Stationary Office, Norwich. Further information Musculoskeletal (orthopaedic) physicians: The British Institute of Musculoskeletal Medicine, 34 The Avenue, Watford,Herts, WD17 4AH 01923 220999, www.bimm.org.ukPhysiotherapists and doctors The Society of Orthopaedic Medicine, 6 Court View Close, Lower Almondsbury,Bristol, BS32 4DW 01454 610255, www.soc-ortho-med.orgWorkshops, seminars and courses on brief, solution-focused effectivecounselling and communication skills: suitable for all healthcareprofessionals: MindFields College, Church Farm, Chalvington, East Sussex, BN27 3TD 01323 811440 www.mindfields.org.uk/humangivensDr Grahame Brown BSc MRCGP DipSportsMed AFOM HGdip FFSEM(RCSI)is amusculoskeletal (orthopaedic) and sports physician and specialist inoccupational and psychological medicine at the Royal Orthopaedic Hospital NHSTrust, Birmingham. He is hon. senior clinical lecturer at The Institute of OccupationalHealth, the University of Birmingham, and consultant to the occupational healthteam at Land Rover vehicles and to a number of professional sports teams andmusicians. He integrates a variety of orthodox and selected complementary treatmentsand therapies into patient management. [email protected] 1: Psychosocial key points– Psychological factors have aconsiderable influence on pain and disability, and a stronger influence onoutcome than biomedical factors– The shift from medical to bio-psychosocial models of illnesshighlights the major importance of psychological factors– Important factors are distress, beliefs and attitudes, painbehaviour and pain-coping strategies– Psychological factors in response to acute pain arepredictive of chronic incapacity– There needs to be a redirection from investigations into thenature of pain towards obstacles to recovery– Distress at and confusion about previous treatments have apowerful influence on a patient’s reaction to pain and disability– There is an urgent need to develop the integration ofpsychological perspectives into the clinical practice of all health careprofessionals– Better management of psychological reactions at early stagesof treatment has the potential to reduce distress and prevent unnecessarychronicityBox 2: Psychosocial warning signsAttitudes and beliefs about pain– Pain is always harmful– Pain must be abolished before return to activity– Catastrophising, ie, thinking the worst, misinterpretingbodily symptoms– Belief that pain is uncontrollable– Passive attitude to rehabilitationBehaviours– Withdrawal from normal activities, substituted withnon-productive time – Poor compliance with exercise. All-or-nothing approach toexercise– Reliance on aids or appliances– Substance abuse, especially smoking and alcoholEmotion– Fear of pain– Depression– Anxiety, irritability, distress, post-traumatic stress– Fear of moving (kinaesiophobia)– Learned helplessness and hopelessness– Anger– All of the above are states of high emotional arousal andwill manifest with sleep disturbance, cognitive impairment (typicallyblack-or-white, all-or-nothing thinking patterns) and physiological symptomsDiagnosis and treatment – Health professionals sanctioning disability– Conflicting opinions and advice, accepting opinions as fact– Behaviour of health professionals, dependency on treatments,over-controlling therapists– Prolonged courses of passive treatments that clearly are notworking– Advice to give up work– Over-reliance on investigations, dramatisation and medicallabelling: ‘arthritis in the spine’, ‘crushed discs’, ‘trapped nerves’, ‘giveup work or you will end up in a wheelchair’Family– Over-protective partner, emphasising fear avoidance andcatastrophising– Solicitous behaviour from spouse– Socially punitive responses from spouse, eg, ignoring– Lack of support– Cultural beliefs and behavioursCompensation issues– Lack of incentive to return to work– History of claims for other health problems– Disputes over eligibility – “How can you get better ifyou have to prove you are ill?”– Persistent focus on ‘diagnosis’ and cause rather restorationof function and health– Ill health retirement benefit issues– Previous experience of ineffective case managementWork– Poor job satisfaction, feels unsupported, frequent job changes– Poor relationship with managers, supervisors, co-workers– Belief that work is harmful– Minimal availability of selected or alternative duties, or agraduated return to work, “Don’t come back until you are totally better”– Low socio-economic status– Job involves significant biomechanical demands– Stress at work: eg, relationships, perceptions, bullyingCase historyAlison, a 50-year old lady, had beenpresenting to health care professionals with back pain and a variety ofdisturbed sensations for the best part of two years. She had had some troublewith her back for many years, but was feeling much more pain now and the painwas gradually getting worse. She was starting to take off a significant amount of time fromher job as a secretary in a large organisation. Spells of absence up to fourweeks at a time were accumulating, totalling 11 weeks during the previous year.She had no symptoms of serious pathology and no nerve rootpain. She had gained weight in the past year. Various courses of physiotherapyhad failed to make any difference to the pain or disability, and blood tests,including thyroid function, arranged by her GP, were negative. The GP did notknow what to do next and asked for an opinion. Importantly, the patient had notcome to the attention of occupational health staff.The patient had been told in the past that she had arthritis inher spine and had been advised to give up swimming, as breast stroke can onlymake this worse (another of the nonsense myths circulating about back pain).Her sleep pattern was very disrupted and she was feeling low in her mood. Heremployer was supportive, but she sensed that this might not always be the case.There did not appear to be any obvious problems at work or at home. I was curious to find out what life events had occurred twoyears ago at the time when she started to present with back pain. It did nottake long to discover that her mother her died. Non-verbal cues indicated thatshe was still grieving and her sleep disturbance had started at the time of herbereavement. Physical examination revealed nothing more than segmentalstiffness in the upper lumbar region.I explained to her that heightened emotional arousal, reflectedin the poor sleep quality, had served to raise her sense of somatic awarenessand lower her tolerance to pain and discomfort. A simple explanation of themind-body system was sufficient to reassure her. I acknowledged her grief andencouraged her to talk more about her feelings with her husband over the comingweeks. Advice to stop exercising and instilling fears of disease had only madematters worse. Her X-rays had merely shown age-related changes. Her back washurting because of excessive muscle tension crimping joints tight and her backwas out of condition. Simple and brief solution-focused counselling on that onevisit was sufficient to break the cycle of pain and depression. I advised herto return to the physical activities that gave her pleasure. I did not think thatany further physical treatments would serve any useful purpose in this case.The whole consultation took no more than 45 minutes.At review six weeks later her depressed mood had lifted, hersleep was refreshing, she was enjoying swimming and her weight was coming off.She was much more positive about her work. And coincidentally, the back painwas now only an ache she could manage with. All her other distressing symptomshad vanished. She felt confident enough to request no further follow up ortreatment.   Related posts:No related photos. Previous Article Next Article Back to workOn 1 Nov 2002 in Musculoskeletal disorders, Personnel Today Comments are closed. last_img read more

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