Summary

Low back pain (LBP) is common in working age-group. Their impact on working life can interfere with activities at work, productivity, sickness absence, long term incapacity and medical retirement. The aim of the project is to systematically develop an evidence-based guideline for the management of LBP in working population in primary care. The Working Group consisted of primary care doctors with expertise in evidence-based medicine, guideline development, health promotion and occupational health. The methodology involved systematic search in database, literature review and critical appraisal. The recommendation statements developed were based on the level of evidence. Consensus were reached through Delphi technique. Peer review was conducted.

Implementation plan was proposed for improving adherence.

摘要

腰背痛（LBP）在工作年齡段的人群中很常見。它可影響工作生活，干擾工作活動、生產力，並可導致病假缺勤、長期失能和因病退休。本專案的目的是為在基層醫療管理工作人群的腰背痛而系統地制定循證指南。工作組由在循證醫學、指南制定、健康促進和職業衛生方面富有經驗的基層醫生組成。採用的方法包括系統搜索資料庫、檢索文獻和批判性評估。根據證據的級別提出了建議意見。通過 Delphi 法取得共識，並進行了同行評議。提出了實施計劃以便提高遵守度。

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Introduction

Low back pain (LBP) is a common reason for seeking health care, and is one of the commonest health reasons given for work loss.^1,2 Among working adults, 60-80% have experienced LBP at some time, and it is often persistent or recurrent. Physical demands of work (manual materials handling, lifting, bending, twisting, and whole body vibration) can be associated with increased back symptoms, aggravation of symptoms and ‘injuries’.^3,4 Care-seeking and disability due to LBP depend more on the complex individual and work-related psychosocial factors than on clinical features or physical demands of work.^3,4 Effective management strategies based on sound evidence are necessary to tackle this common problem. Nevertheless, local evidence based occupational guidelines and studies are lacking. It is important to explore and develop this aspect in primary care.⁵. This paper describes the development of an evidence-based primary care guideline on the management of low back pain among the working population.

Prevalence

The lifetime prevalence of LBP has been estimated at 59% to 90%,⁷ with an annual incidence of approximately 5%.⁸ Among the Dutch general population, the annual prevalence was found to be about 50%.9 This Dutch study also showed that in patients with LBP, 28% were restricted in their daily activities, 42% underwent medical treatment, 23% took time off work, 8% received disability pension, and 6% changed jobs or had adaptations in the workplace.⁹

In Hong Kong, an estimated 57.1% and 42.1% of the population suffered from low back pain at least once in their life time and at least once within the past year respectively.10 In a cross-sectional telephone survey involving 10072 subjects, 6760 episodes of work-related illnesses were reported,10 with 14.6% suffering from LBP.26 LBP was the second most prevalent illness caused by work and the commonest illness made worse by work.¹⁰ Sick leave was taken in 10% of the episodes of work related illnesses.10 Among the 3 million working people in Hong Kong, around 900,000 days of sick leave were granted and HK$513 million were paid for doctor consultation because of work related illnesses annually.¹⁰

Definitions

Low back pain is defined as pain at the posterior trunk between the ribcage and the gluteal folds. It includes low extremity pain that results from low back disorder (sciatica/radiating low back pain), whether there is trunk pain or not. Sciatica is radiating, lower extremity pain and may not be associated with back pain.⁶ Acute LBP is defined as pain that lasts less than six weeks (or four in some studies), sub-acute LBP lasts for six (or four) to twelve weeks, and chronic LBP lasts for longer than twelve weeks. Acute non-specific LBP is defined as back pain that has not lasted more than 6 weeks and does not radiate down the leg or to below the knee, and without features suggestive of potentially serious conditions.⁶

Management of low backpain – development of an evidence-based guideline

Method

A guideline was developed by the Guideline Development Working Group on evidence-based management of low back pain in working population in primary care. This group was formed in 2010, comprising primary care doctors with expertise in evidence -based medicine , health promotion, clinical audit and guideline development; as well as occupational health and safety officers. 

Systematic search was performed in Medline, the Cochrane Library, various websites including the US National Guidelines Clearinghouse, NICE websites, SIGN websites, New Zealand Guideline Group websites, occupational Safety and Health websites of Hong Kong, USA, UK, other EU members, Australia, New Zealand, Singapore, Labour Department of HK, other Asian Countries, UK, USA, Australia and New Zealand. Reviews on international guidelines on occupational health practice for back pain were conducted and critically appraised: UK,^12-13 Australia,^14-16 USA,^17-18 Canada,¹⁹ New Zealand²⁰ and Europe^21,22 and were adopted according to local applicability and level of evidence.

Search terms used included low back pain, LBP, low back symptom, non-specific low back pain, prolapsed disc, PID, back injury, back sprain, back ache , backache , treatment low back pain, therapy low back pain, occupational low back pain, occupational musculoskeletal disease, occupational musculoskeletal disorder, occupational injury, injury on duty, injury job related, etc. Limits were applied to reviews, systematic reviews, randomized controlled trials (RCTs), meta-analysis and guidelines from 1990-2010.

Guideline working group members assessed the titles and abstracts of the literature searched, using a checklist with a prior defined selection criteria. Relevant studies were retrieved and the full articles were critically appraised by guideline working group members for inclusion. Methodological quality was assessed by Oxford methods for critical appraisal of RCTs and meta-analysis; whereas guidelines were assessed by the Appraisal of Guidelines Research and Evaluation tool.

Regular meeting s were held to review the literatures, identify evidence and develop recommendation statements through structured communication in a panel of working group members. The level of evidence was identified and strength of recommendation defined according to the Scottish Intercollegiate Guidelines Network. Consensus was reached through discussion and by the Delphi technique. Peer review was conducted after the draft was completed. External review was also conducted by professionals with expertise in occupational medicine. Implementation plan was also developed to promote practice improvement and compliance to the guideline.

Results

The followings are the results of the guideline development. They are under the heading of prevention, assessment, management of back pain and management of prolonged back pain. (Table 1). The algorithms of the management of the LBP are shown in Figure 1. The results of the Cochrane systematic reviews on the effectiveness of different treatment modalities are summarized in Appendix 1.

Prevention

Evidence identified

Traditional biomedical education and lumbar supports do not reduce future LBP and work loss.^22,23 (Evidence level 2)

Lumbar belts or supports do not reduce work-related LBP and work loss^22,23 (Evidence level 2). Low job satisfaction and unsatisfactory psychosocial aspects of work are risk factors for reported LBP, health care use and work loss, but the size of that association is modest.4 (Evidence level 2)

Joint employer-worker initiatives to monitor and improve safety can reduce the number of reported back ‘injuries’ and sickness absence. It involves organizational culture and high stakeholder commitment to identify and control occupational risk factors and improve safety, surveillance measures and safety culture.²³ (Evidence level 2)

There is preliminary evidence that educational interventions which specifically address beliefs and attitudes may reduce future work loss due to LBP.²⁴ (Evidence level 4)

According to Cochrane systematic reviews, there is limited evidence that manual material handling advice and training could prevent back pain, back pain-related disability or reduce sick leave when compared to no intervention.²⁵ (Evidence level 2)

Recommendations

Advise employers that high job satisfaction and good industrial relations are the most important organizational characteristics associated with low disability and sickness absence rates attributed to LBP. (Grade B recommendation)

Do not recommend lumbar belts and supports or traditional biomedical education as methods of preventing LBP. (Grade B recommendation)

Advise on current good working practices such as manual handling technique. (GPP) 

Encourage employers to consider joint employer-worker initiatives: (Grade D recommendation)

– identify and control occupational risk factors.

– improve safety and develop a ‘safety culture’.

– recognise the importance of providing satisfying work in a climate of good industrial relations.

– monitor back problems and sickness absence due to LBP.

Assessment of LBP workers

Evidence identified

Screening for ‘red flags’ and diagnostic triage is important to exclude serious spinal diseases and nerve root problems.²⁶ (Figure 3) (Evidence level 2)

Individual and work-related psychosocial factors play an important role in persisting symptoms and disability, and influence response to treatment and rehabilitation.

Screening for ‘yellow flags’ can help to identify those workers with LBP who are at risk of developing chronic pain and disability. Workers’ own beliefs that their LBP was caused by their work and their own expectations about inability to return to work are particularly important.^1,26,27,30 (Figure 4) (Evidence level 1)

In patients with non-specific LBP, X-ray and MRI findings do not correlate with clinical symptoms or work capacity.²⁸ (Evidence level 2)

Patients who are older (particularly >50 years), have more prolonged and severe symptoms, have radiating leg pain, whose symptoms impact more on activity and work, and who have responded less well to previous therapy are likely to have slower clinical progress, poorer response to treatment and rehabilitation, and more risk of long term disability.^27,29 (Evidence level 2)

Recommendations

Take a clinical, disability and occupational history, concentrating on the impact of symptoms on activity and work, and any obstacles to recovery and return to work. (Figure 1) (Grade A recommendation) 

Screen for serious spinal diseases and nerve root problems. (Grade A recommendation)

Consider psychosocial risk factors for chronicity and disability in assessment. (Figure 2) (Grade A recommendation)

Do not recommend X-rays and scans for patient with acute non-specific low back pain. (Grade C recommendation)

Management principles

Evidence identified

Staying active and returning to ordinary activities as early as possible leads to faster recovery and fewer recurrences. (Level 1 evidence)

There is strong evidence that the aforesaid advice can give equivalent or faster symptomatic recovery from the acute symptoms, and leads to shorter periods of work loss, fewer recurrences and less work loss over the following year than ‘traditional’ medical treatment.^26,31

Most workers with LBP are able to continue working or to return to work within a few days or weeks: they do not need to wait until they are completely pain free.²⁶ (Level 1 evidence)

Advice to be away from work for as short a time as possible in order to improve the chance of being able to resume work.26 (Level 2 evidence) 

There is strong epidemiological evidence that the longer a worker is off work, the lower their chances of ever returning to work.26 Low back pain is commonly a persistent or recurrent problem and most workers do continue working or return to work while symptoms are still present.26 The above advice can be usefully supplemented by simple educational interventions specifically designed to overcome fear, avoidance beliefs and encourage patients to take responsibility for their own self-care.^26,32

There is moderate evidence that the temporary provision of lighter or modified duties facilitates return to work and reduced time off.92 Recommendations should include staying active but avoiding heavy lifting, bending, twisting, and prolonged sitting.²⁰ (Level 3 evidence)

Communication, co-operation and common agreed goals between the worker with LBP, the occupational health team, supervisors, management and primary health care professionals are fundamental for improvement in clinical and occupational health management and outcomes.^26,34 (Level 3 evidence)

Workplace organizational and management strategies generally involve organizational culture and high stakeholder commitment to improve safety, provide optimum case management, encourage and support early return to work.^3,26 (Level 3 evidence)

There is moderate evidence from systematic review that a combination of optimum clinical management, a rehabilitation programme and organizational adjustments designed for worker returning to work is more effective than single elements alone.^33,35,36 (Level 1 evidence)

Recommendations

Address the common misconception among workers and employers of the need to be pain free before returning to work. (Grade A recommendation)

Encourage the worker to resume / continue ordinary activity including their work as normally as possible despite some remaining low back pain. (Grade A recommendation)

Encourage worker to negotiate with work supervisor to consider temporary modification of work duties to facilitate return to work and reduce sick leave due to low back pain. (Grade C recommendation)

Initiate communication and liaise closely with patient’s health professionals and other related stakeholders early in treatment and rehabilitation (Grade C recommendation)

Approximately 4 – 12 weeks

Evidence identified

The longer a worker with LBP is off work, the lower his chances of ever returning to work. Once a worker is off work for about 4-12 weeks. He has a 10-40% risk (depending on the setting) of still being off work at one year; after 1-2 years’ absence it is unlikely he will ever return to any form of work in the foreseeable future, irrespective of further treatment.1 (Level 3 evidence)

Various treatments for chronic LBP may produce some clinical improvement, but most clinical interventions are quite ineffective at returning people to work once they have been off work for a protracted period with LBP.³⁷ (Level 2 evidence)

Temporary provision of modified or lighter duties facilitates return to work and reduces time off work.³⁸ (Level 3 evidence)

A combination of optimum clinical management, a rehabilitation programme, and organisational interventions designed to assist the worker with LBP to return to work, is more effective. Changing the focus from purely symptomatic treatment to an ‘active rehabilitation programme’ can produce faster return to work and less chronic disability.^34,37,39,40 (Level 1 evidence)

Recommendations

Address the common misconception among workers and employers of the need to be pain-free before return to work. Some pain is to be expected and the early resumption of work activity improves the prognosis. (Grade B recommendation)

Advise on ways in which the job can be adjusted, in order to facilitate return to work. (Grade C recommendation)

Communicate and collaborate with primary health care professionals to shift the emphasis from dependence on symptomatic treatment to rehabilitation and self-management strategies. (Grade B recommendation)

Ensure that workers, employers and primary care health professionals understand that the longer anyone is off work with LBP, the greater is the risk of chronic pain and disability, and the lower the chances of ever returning to work. (GPP)

Encourage the employer to establish a surveillance system to identify those off work for over 4 weeks so that appropriate action can be taken. (GPP)

Discussion and conclusion

LBP is still one of the commonest causes of sickness absence, long-term incapacity and early retirement. Given the right care, support and encouragement, most people with LBP should be able to remain in or return to work. Evidence shows that interventions are effective in reducing sickness absence and the number of people proceeding to long-term incapacity. In addition, effective intervention requires different stakeholders (including workers with LBP, employers and health professionals) to work together towards a common goal or better outcomes. To bridge between research and practice, efficient delivery of effective interventions is crucial. Active educational intervention is one of the ways for effective dissemination.

Interventions to promote implementation with evidence of effectiveness include: reminders, educational outreach, interactive educational activities and by feedback. Clinical audit could be used to monitor and evaluate of dissemination and implementation of the guideline. It is a quality assurance activity to ensure effective interventions implemented are sustainable and to promote standard of management. 

Acknowledgement

Our special thanks to Dr Ruby Lee, Consultant (Family Medicine), Elderly Health Service, Dr Linda Hui Consultant (Family Medicine), Professional Development and Quality Assurance and Dr Luke Tsang, formerly Consultant (Family Medicine), Service Head, Professional Development and Quality Assurance, Department of Health for support and guidance. Last but not least, I would like to extend my deepest appreciation to the continuous team effort of all dedicated members of the Guideline Development Working Group on evidence-based management of low back pain in working population in primary care without which the review could not be realized.

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References