Managing low back conditions and low back pain
Richard Graveling, C.ErgHF; FCIEHF, Institute of Occupational Medicine, Edinburgh, UK
Introduction: What is lower back pain?
According to Waddell & Burton (2000):
“Most adults (60-80%) experience LBP [Low Back Pain] at some time, and it is often persistent or recurrent. It is one of the most common reasons for seeking health care, and it is now one of the commonest health reasons given for work loss.
Low back pain can arise from many different parts and structures within the back. As well as bone (the spinal column) and discs (the intervertebral discs) the back includes muscles, ligaments, tendons, nerves and blood vessels; any one of which can give rise to pain.
Sometimes the source of the pain can be identified, as in the case of pain stemming from a bulging or prolapsed intervertebral disc. One clinical study found the facet joints (small joints forming part of the interface between adjacent discs) to be the commonest source of chronic low back pain (40% of cases) followed by the disc (26% of cases). However, the authors commented that soft tissue sources, such as muscle pain or ligament pain, were associated with the least scientific evidence. The study was also based on a series of patients whose pain had not been resolved by conventional conservative management such as rest or physiotherapy (unlike many with so-called ‘mechanical’ or ‘soft tissue’ back pain).
In addition to prolapsed discs, many other specific clinical conditions can give rise to back pain, including:
- ankylosing spondylitis (swelling of the joints in the spine);
- spondylolisthesis (where a bone in the spine becomes displaced);
- spinal stenosis (in which the bone surrounding the spinal column grows and starts to compress the spinal cord);
- osteoporosis (loss of bone density sometimes leading to vertebral compression injuries – where the weakened bone collapses);
The latter condition occurs when the sciatic nerve is irritated, possibly (but not always) associated with a prolapsed disc. For example, inflammation or direct pressure from an adjacent muscle can also lead to sciatic nerve irritation. Although commonly associated with leg pain (due to irritation of the sciatic nerve) it can also lead to low back pain (with or without leg pain). Low back pain can also be a result of degenerative conditions such as osteoarthritis, and many women suffer from low back pain during pregnancy.
The list above presents only a few of the specific conditions that can give rise to low back pain; there are many more. To further complicate the issue, low back pain is not always accompanied by physical signs. For example, an individual reporting pain apparently consistent with a prolapsed disc might not display any such prolapse on an MRI scan (equally, some in whom a scan reveals a significant prolapse might nevertheless be pain free).
Despite this long list of clinical causes of low back pain, in the majority of people, the specific source of their low back pain cannot be identified. Such conditions are often referred to as ‘non-specific back pain’ or ‘mechanical back pain’. The reported lack of scientific evidence relating to such forms of back pain is probably due to the difficulties in researching this non-specific low back pain, where the specific source or structures giving rise to the pain cannot be readily identified. Researchers are often then restricted to studying ‘low back pain’ as a broad and non-specific symptom, thus combining many of the different sources and causes into one over-arching condition.
In some cases, such pain will be attributed to ‘soft-tissue’ injury, resulting from some form of overstrain or other challenge of the muscles of the low back. In many instances for example, the pain might take the form of a muscle ‘spasm’. Superficially this can be regarded as a form of cramp although, unlike cramp (which usually passes in a few minutes, perhaps just leaving some residual soreness) the spasm can last for a few days, only gradually receding.
The management of back pain at work – avoiding what causes pain
Although primary efforts in the workplace should be addressed at removing or reducing possible causes of back pain it will be apparent from the list above that low back pain can arise from a wide variety of conditions unrelated to work. Many of these are to some extent age-related and, given the increase in the numbers of older workers and a growing trend for an ageing workforce, the incidence of such conditions, and therefore of low back pain, amongst the working population is likely to increase.
Attention must therefore also be directed towards assisting those with low back pain to remain in work or, should they experience an incapacitating episode of back pain, to return to work at the earliest opportunity.
“People who go off work are less likely to return than those who stay and make changes”
In addition to the recognised benefits of keeping people with back pain at work, there is a growing recognition that, for those who do require to take some time off, early return to work in some capacity is important and that, the longer an individual remains absent the harder it becomes for them to return.
“Remaining at work or returning early does not increase the risk of reinjury and can help decrease missed work days, chronic pain, and disability".
In such cases, the emphasis is not only on preventing exposure to factors likely to create a risk of back injury; but also on avoiding factors that cause or exacerbate existing pain (as there will often be considerable overlap between these sets of factors, especially in more manual jobs).
Managing risk factors
Managing such factors requires an integrated approach and, depending upon the circumstances, may involve various different players within the work organisation. This may include: health professionals who can advise on the specific actions causing problems; ergonomists who can advise on work and workplace design adjustments that would avoid such actions; engineers and others who can assist in designing (or re-designing ) workplaces if necessary; and line management to ensure coordination and compliance. Where such input is not available in-house (e.g. in smaller enterprises) it might be necessary to seek the services of external professionals.
However, central to any discussions should be the employee themselves. Involving the individual in any decision-making is key and listening to them, understanding the nature of the problem and their ideas for solutions should be a central part of the process.
For those who usually sit at work, simple measures might include alternatives to conventional sitting (e.g. sit-stand or standing workstations). There are some who advocate the wider use of standing workstations although, for some, prolonged standing can exacerbate their pain. It is increasingly being recognised that the human body is designed for movement and lack of such movement (whether sitting or standing) is likely to lead to problems. Changes in posture can help to relieve back pain. This can perhaps be achieved by simply getting up and walking about occasionally although others might benefit from being able to vary between sitting and standing when working. Such activity does not need to take the form of formal exercises (e.g. stretching) although again some individuals might find this helpful. However, stretching (particularly of muscles that have remained still for some time) is not without risk – and for some can trigger an episode of pain. Increasingly it is being said for workers “your next posture is your best posture”, which is to say that all workers should adopt a variety of good postures throughout the working day. In view of this employers should promote a culture of taking breaks and working more dynamically for the whole workforce.
For those in more manual jobs, aids to reduce or remove the need for manual handling (such as simple trolleys to move material around, rather than carrying it) or measures to reduce the amount of bending or stretching required (such as height adjustable work platforms) can be beneficial. However, there is no evidence that lumbar supports or back belts provide an effective solution. Other measures to consider include job rotation or task redistribution. Some changes may only need to be temporary, such as changes in duties and activities to avoid activities that exacerbate back pain such as manual handling or heavy lifting, changes in working hours, or temporarily allowing longer or more frequent breaks to enable employees to stretch or exercise.
Of course, the widespread introduction of measures designed to reduce the strain on the back can help the whole workforce, not just the back pain sufferer. A risk assessment should be carried out to identify the measures and should be ongoing for all manual handling jobs and the training involved. Likewise, initiatives such as running health promotion training programmes about back care and how to prevent low back problems would be beneficial for the whole workforce.
Whatever the job and whatever the measures adopted, alternatives may need to be explored on a trial and error basis before the best solution is found. It is certainly not the case that ‘one size fits all’ when it comes to finding solutions to help those with back pain remain at work and manage their condition.
Managing the individual
As noted above, an early return to work is important and an essential part of that is managing the attitudes of all those involved, including in particular the individual sufferer. Historically, some managers have displayed a reluctance to accept a phased or partial return to work, adopting an attitude of ‘either you are fit for [all] your job or you are still sick’. It is important that all involved appreciate that a gradual return to work over a period, with appropriate workplace adjustments (temporary or otherwise) emphasising what a person can do rather than what they can’t do, will help to ensure a faster and more permanent return to effective productive employment than waiting until an individual is fully ‘fit’.
A key element in this is the individual themselves. It is vital for the individual sufferer to understand the (sometimes) difficult distinction between provoking pain from an existing condition and causing that condition; and that it can be important to avoid becoming over-protective. A degree of discomfort or pain is not necessarily harmful and careful controlled use of the affected muscles can aid recovery. Managing the individual’s perception of the interplay between symptoms and work is key. If they develop the mind-set that work has somehow ‘caused’ their pain (which may or may not be correct) it can become hard to persuade them to return to that work, even when the episode of pain has subsided. In some instances, some form of ‘cognitive therapy’ might be helpful to change how people think about and cope with their symptoms but, in other cases, simply avoiding a negative attitude and approach can be effective.
As part of these, the wider psychosocial environment is also important. It has been recognised for many years that psychosocial factors can contribute to the risk of back pain and other MSDs (e.g. Bernard, 1997). However, such factors can also contribute to difficulties in achieving an effective return to work (or remaining in work) amongst back pain sufferers. Although an over-simplification there is some truth in the idea that if an individual is happy and content in their work then they will have a more positive attitude towards that work and continuing in it. Conversely, poor job satisfaction, or discontent with other specific elements of a job, will tend to foster a reluctance to return to the work that is seen as responsible for their pain and suffering while high positive expectations can help foster an early return.
Don’t leave it too long
Although the causes of much back pain are non-work-related, work activities can exacerbate such problems or cause the sufferer difficulties at work. Encouraging early reporting and early action is vital, possibly leading to avoiding the individual’s need to go off work as a result. Some individuals might take the view that a problem is ‘part of getting old’ and do not necessarily appreciate that, whether symptoms are seen as due to work or not, it is important to ‘catch’ them early rather than ‘suffer in silence’.
“If you are having problems working because of pain in your back, neck, shoulders, arms or anywhere else, we want to help. Come in and talk to us!”
Making early simple adjustments to workplaces, activities or routines can be relatively easy to adopt in the early stages and can often delay or avoid the need for more dramatic changes or restrictions in work activities at a later stage. Some employers with an older workforce or for those working in jobs with a risk of back problems find it beneficial to provide support to workers to access physiotherapy.
Everybody has a role to play
While employers have specific duties to identify, reduce or remove relevant risks, individual employees also have a role to play in keeping their back healthy – especially if they have had episodes of pain in the past. Thus, for example, although an employer has a duty to provide a suitable workstation for computer users, the individual needs to play their part in using that workstation correctly, in sitting and working with a good posture, and in taking the regular short breaks prescribed.
Combined with general healthy lifestyle issues; preventative actions, (and early interventions) can help reduce the risk of an acute episode of back pain becoming chronic or can lessen the impact of chronic conditions.
In fact, encouraging a modest degree of physical activity can be beneficial for all employees, not just those with back pain, and encouraging an active workforce with regular breaks and physical movement will help maintain a healthier (and happier) workforce.
Throughout, a spirit of cooperation and collaboration is essential. Everybody benefits. The employee remains at work – without that work causing them pain and discomfort – and the employer retains an employee they have invested time and resources in recruiting and training.
Sources of further help and advice
- Waddell, G, Burton K. (2000) Occupational health guidelines for the management of low back pain at work. Evidence review. London: Faculty of Occupational Medicine
- Manchikanti, L., Singh, V., Pampati, V., Damron, KS., Barnhill, RC., Beyer, C., Cash, KA. (2001) Evaluation of the relative contributions of various structures in chronic Low Back Pain. Pain Physician, 4: 308-316.
- Breen, A., Langworthy J., Bagust J. (2005) Improved early pain management for musculoskeletal disorders. London: HSE Books (RR 399) (http://www.hse.gov.uk/research/rrpdf/rr399.pdf)
- Nguyen, TH., Randolph, DC. (2007) Nonspecific low back pain and return to work. Am Fam Physician; 76:1497-1502, 1504.
- Verbeek, J., Sengers, M.-J., Riemens, L., Haafkens, J. (2004) Patient expectations of treatment for back pain. Spine; 29: 2309-2318.
- Burton et al (2004) European guidelines for prevention in low back pain. European Commission COST Action B13.
- BackCare (2009) Key facts on back pain at work for employers. BackCare. London. http://backcare.org.uk/wp-content/uploads/2015/02/Back-Facts-for-Employers-Factsheet.pdf
- EU-OSHA (2007) Factsheet 73 - Hazards and risks associated with manual handling of loads in the workplace. European Agency for Safety and Health at Work (https://osha.europa.eu/en/tools-and-publications/publications/factsheets/73/view)
- Waddell, G. Burton, A. (2004) Concepts of rehabilitation for the management of common health problems. London, The Stationery Office.
- Bernard, B. (ed). (1997) Musculoskeletal Disorders and Workplace Factors. US Department of Health and Human Services, Public Health Service Centres for Disease Control National Institute for Occupational Safety and Health. DHHS (NIOSH) Publication 97-141, Cincinnati, OH
- Opsahl, J., Eriksen, HR., Tveito TH. (2016) Do expectancies of return to work and Job satisfaction predict actual return to work in workers with long lasting LBP? BMC Musculoskeletal Disorders (2016) 17:481.
- EU-OSHA (2016) Denmark — Never too old for the kindergarten: reducing the strain to retain employees. European Agency for Safety and Health at Work (https://osha.europa.eu/en/tools-and-publications/publications/denmark-never-too-old-kindergarten-reducing-strain-retain/view)