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Back Pain – 

A Guide for Human Resources and Management

Lower Back Pain

Background

Back pain can be very disabling. The level of pain may be greater than any other pain experienced before. Unfortunately, the advice given to patients with back pain is often wrong, and patients who listen to bad advice often experience worse symptoms for longer, and many remain disabled long-term. Studies have shown that opinions given without reference to evidence are wrong more often than not, and this is a particular problem with back pain. Nurses, doctors, physiotherapists, porters, receptionists and ambulance staff will all offer their opinions on the cause, the treatment and the prognosis, and often they will be wrong. Around 80% of us will have at least one episode of severe back pain at some point, and in around 95% of cases no objective cause will be identified. A complete recovery is expected.

If humans were as vulnerable to back injury as is often suggested, and the injuries were as severe as is often suggested, the human race would not exist. We have coped with back pain for hundreds of thousands of years by just getting on with life; the symptoms have settled very quickly and recovery has been complete. The main reason that back pain has become such a problem for humans in the last fifty years is because people with back pain don’t just get on with life; they rest, stiffen up and develop chronic problems as a result. Why? Because very occasionally someone does develop serious back pathology with permanent serious damage, and everyone is worried that they could do so too. Also, the best treatment for simple back pain is to keep active and that hurts, initially it hurts a lot.

Back Pain – The Facts

Red, Yellow, Blue And Black Flags

Simple Or Mechanical Back Pain

If there are no red flags, and pain is restricted to the lumbar region, the appropriate diagnosis would be ‘simple’ or ‘mechanical’ back pain. It is extremely unlikely that any objective cause for the pain will be found.

Imaging For Simple Back Pain

Guidelines all recommend against imaging in these circumstances for a very good reason. Imaging will find all sorts of degenerative changes, but the evidence shows very clearly that there is no good link between symptoms of simple back pain and underlying degenerative changes. An MRI is usually unhelpful in these circumstances. Studies have shown significant numbers of 13 year olds are showing degenerative changes in the intervertebral discs, and by the age of 40 over 50% of adults have some degeneration, with disc bulging, disc tears or facet joint changes, all collectively referred to as ‘spondylosis’ (Kjaer et al 2005). The degenerative changes seen in disc fibres are the equivalent of wrinkles in the skin. They happen to everyone, and there is no miracle cure to prevent them. The great majority of adults have degeneration by the age of 60; however consultations for back pain peak in the 40’s and decline significantly over the age of 60 (Croft et al 1998). In most cases MRI findings are unrelated to symptoms and are therefore poor diagnostic tools and poor prognostic indicators (McNee et al 2011). The only clear finding in recent studies is a link between Modic 1 changes (vertebral endplate inflammation) and low back pain (Albert et al 2011). In most cases of inflammation the symptoms settle over time and a full recovery is expected.

Treatment for simple back pain

The treatment is activity and, where necessary, pain killers (analgesia). Analgesia is only needed to aid activity. Early stretching is often effective. Rest prolongs pain and leads to stiffness. Stiff backs are often painful, so a permanently stiff back is likely to be permanently painful.

Ninety percent of acute low back pain settles within six weeks, regardless of treatment. Chronic back pain is defined as back pain that has persisted for longer than three months. Physiotherapy can be helpful in cases of chronic back pain. Chronic pain is usually related to maladaptive and abnormal central processing of pain rather than any residual local back pathology.

Surgery is rarely offered as treatment for simple back pain because there is no evidence that it is effective, while morbidity associated with surgery can be substantial.

Slipped disc

Discs don’t slip. If you tell someone you have back pain, the most common response is ‘you probably have a slipped disc’. GPs often tell patients they have a ‘slipped disc’ as do physiotherapists, chiropractors and osteopaths. This is unhelpful, but not as unhelpful as saying ‘you have a crumbling spine’.

Discs do prolapse or herniate (but don’t ‘slip back in’), and this is just a normal variant of disc degeneration. Many individuals remain entirely asymptomatic after disc herniation (Kjaer et al 2005). In the absence of any clear objective link between symptoms and a disc herniation seen on MRI, this finding should be regarded as incidental. If the symptoms are those of simple back pain, that is the appropriate diagnosis.

‘Sciatica’ and nerve root irritation

Back pain may be associated with symptoms of pain, numbness, pins and needles and weakness in the leg. Various terms are used to describe this. Where the pain is in the buttock and down the thigh with no other symptoms it is almost invariably referred pain, and the problem is simple or mechanical back pain. The term ‘sciatica’ is often used for referred pain and is inappropriate and unhelpful, because it implies that the sciatic nerve is somehow involved.

True nerve root involvement is uncommon: less than 5% of episodes of severe back pain. The diagnosis should be made by a health professional.

Classically, where there is true nerve root irritation the leg pain is worse than the back pain. Most cases of nerve root irritation settle as the associated inflammation settles. There is no specific treatment needed, and activity won’t generally cause harm. There is a risk that more of the central part of the disc (nucleus pulposus) will herniate over time, and that this may be associated with activity, however there is nothing that can be done to prevent this in the long term. If it is going to herniate it will do so; avoiding any activity will merely delay the inevitable. There is no reason to restrict activities on this account.

In a few cases surgical discectomy may be necessary. Discectomy is a straightforward process; it usually causes minimal disruption to surrounding tissues, and there is no reason to restrict activity afterwards. Studies show patients are not harmed by activity, including work, immediately after surgery (Carragee et al., 1999), and, in time, a return to full activities including high impact sports is expected (Dollinger et al., 2008).

Spinal stenosis and spinal claudication

Simple back pain and disc prolapse are more common in younger patients. Spinal stenosis is more common in older patients, seen increasingly from middle age onwards (age >50 years). Where back pain is combined with symptoms of nerve root irritation and compression, particularly pain that increases on walking then settles after a few minutes rest, spinal stenosis may be more likely than a simple disc prolapse. Specialist assessment is recommended and surgical decompression may be the appropriate treatment. Health professionals may well find it difficult to cope with standing, walking and manual handling and adjustments may be needed.

Decompression is often associated with spinal fusion. A full recovery is expected after spinal fusion, and there is no reason to restrict activity, with a return to high impact sports recommended after single level fusion unless the fusion involves C1-2, the cervico-thoracic or thoraco-lumbar junction (Torg and Ramsey-Emrhein, 1997).

The outcome of spinal fusion in smokers is very poor.

Workplace adjustments for low back pain

Many employees with back pain worry about their ability to work, and this can delay a return to work. Work itself is very unlikely to cause harm, so the main aim in recommending adjustments is to ensure the employee is confident they can return to work and stay at work without symptoms worsening. Many health professionals also worry about possible risk to patients should they develop acute back pain while treating or moving a patient.

As everyone’s back pain is different, and everyone responds and recovers differently, the best person to choose adjustments is the person with back pain. There are a number of principles to consider, and these are outlined below.

Patient safety

Care should be taken to avoid putting patients at risk. If the healthcare worker is not confident that they can lift a patient they should not attempt to do so. It is also important that they avoid a procedure that cannot be easily abandoned if back pain worsens. It may be appropriate for them to avoid a situation where there might be a need to restrain a patient who is confused or violent. Special care needs to be given in those working with the elderly or in acute or forensic psychiatry.

Activities likely to exacerbate pain

While some activities might cause a little pain, some may cause progressive symptoms that might become intolerable. Examples are standing for prolonged periods, for example in an operating theatre or dental clinic or in an outpatients clinic, particularly standing in an awkward position. Sitting still can also become painful, particularly if maintaining an awkward position while undertaking a procedure. It may well therefore be appropriate for health professionals returning to work after a period of back pain not to start with theatre lists and treatment clinics, prolonged periods of patient care in busy inpatient settings or tasks involving repetitive lifting, but to start with administration and outpatients clinics where there is more flexibility to move around or rest. Work patterns that reduce work intensity and allow breaks to stretch or rest will also be helpful.

Sitting is not necessarily comfortable, particularly sitting still, and the general recommendation is to either move position on the chair regularly, or get up and stretch regularly. A short walk around the room, or to make a cup of tea, should be considered every thirty to sixty minutes. People are often very concerned about the chair used; a relatively new well maintained adjustable office chair is very unlikely to cause problems. It is not usually the chair that is the problem, but the way the person sits in the chair. A good posture is essential, adjusting the posture regularly whenever discomfort is felt. A posture facing directly forwards is unlikely to cause problems, while it can be very uncomfortable trying to twist to face a screen to one side, or read documents to one side. Work should be positioned centrally while working to ensure a stable neutral posture without having to reach awkwardly. The chair should be adjusted so that the forearms rest comfortably on the desk, with elbows roughly at right angles.

Manual handling may cause pain, but not necessarily. Lifting and carrying small items can often keep the back mobile and help avoid pain. Lifting heavy items may however be very painful and is best avoided initially. Lots of frequent bending and stretching may exacerbate pain. The best way to identify what hurts and what doesn’t is for the individual to try various activities. There is no need for the individual to avoid discomfort entirely; the aim is to keep symptoms at a tolerable level but also to increase activity levels to aid recovery.

Driving may be comfortable for some but very uncomfortable for others, particularly taller people. Consideration needs to be given to health professionals who travel by car to peripatetic clinics and patient encounters, perhaps at home. Individuals should avoid long drives if possible. If a long drive is needed, they should be encouraged to stop and get out of the car at least every hour, to have a stretch and walk around. Therefore extra time may be needed for the journey.

Reducing hours

The thought of working a full week while still having symptoms can be very daunting for anyone. Allowing the health professional to start towards the end of a week, so only a day or two have to be worked before a couple of days off for the weekend, can help. Alternatively start with reduced hours, perhaps half days only, or alternate days. This approach to reduced hours can be combined with a reduced workload or avoidance of particular activities. It can be best to increase hours over several weeks if the pain does not settle quickly; however, there is no need to maintain reduced hours just because it has been agreed beforehand if the symptoms settle very quickly. A review of hours is best undertaken regularly, at least once a week.

Working from home for one day a week or more may be an option for a few health professionals (where type of work allows) on a temporary basis whilst their back pain improves. But trying to work on the corner of a dining table, or sitting on a sofa, is a recipe for worsening symptoms. The same rules should be applied at home for a workstation setup as they would at work.

Managing others returning with back pain

Lack of control over duties can be the biggest factor delaying a return to work. Allowing the individual to choose activities they can cope with, and to stop if symptoms get too much, is a great confidence booster. It is much better to allow someone to come back and just do what he or she can for the first week rather than stay off another week and do nothing.

Sources Of Information:

References:

Albert, H. B., Briggs, A. M., Kent, P., Byrhagen, A., Hansen, C. & Kjaergaard, K. 2011. The Prevalence Of Mri-Defined Spinal Pathoanatomies And Their Association With Modic Changes In Individuals Seeking Care For Low Back Pain. Eur Spine J, 20, 1355-62.

Beutler, W. J., Fredrickson, B. E., Murtland, A., Sweeney, C. A., Grant, W. D. & Baker, D. 2003. The Natural History Of Spondylolysis And Spondylolisthesis: 45-Year Follow-Up Evaluation. Spine (Phila Pa 1976), 28, 1027-35; Discussion 1035.

Brown, C. W., Orme, T. J. & Richardson, H. D. 1986. The Rate Of Pseudarthrosis (Surgical Nonunion) In Patients Who Are Smokers And Patients Who Are Nonsmokers: A Comparison Study. Spine (Phila Pa 1976), 11, 942-3.

Carragee, E. J., Han, M. Y., Yang, B., Kim, D. H., Kraemer, H. & Billys, J. 1999. Activity Restrictions After Posterior Lumbar Discectomy. A Prospective Study Of Outcomes In 152 Cases With No Postoperative Restrictions. Spine (Phila Pa 1976),24, 2346-51.

Croft, P. R., Macfarlane, G. J., Papageorgiou, A. C., Thomas, E. & Silman, A. J. 1998. Outcome Of Low Back Pain In General Practice: A Prospective Study. Bmj, 316, 1356-9.

Dollinger, V., Obwegeser, A. A., Gabl, M., Lackner, P., Koller, M. & Galiano, K. 2008. Sporting Activity Following Discectomy For Lumbar Disc Herniation. Orthopedics, 31, 756.

Kjaer, P., Leboeuf-Yde, C., Korsholm, L., Sorensen, J. S. & Bendix, T. 2005. Magnetic Resonance Imaging And Low Back Pain In Adults: A Diagnostic Imaging Study Of 40-Year-Old Men And Women. Spine (Phila Pa 1976), 30, 1173-80.

Mcnee, P., Shambrook, J., Harris, E. C., Kim, M., Sampson, M., Palmer, K. T. & Coggon, D. 2011. Predictors Of Long-Term Pain And Disability In Patients With Low Back Pain Investigated By Magnetic Resonance Imaging: A Longitudinal Study. Bmc Musculoskelet Disord, 12, 234.

Torg, J. S. & Ramsey-Emrhein, J. A. 1997. Management Guidelines For Participation In Collision Activities With Congenital, Developmental, Or Postinjury Lesions Involving The Cervical Spine. Clin J Sport Med, 7, 273-91.