Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with ...disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause—eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.
Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with ...initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.
Retrospective cohort study.
To determine the effect of early (receipt ≤30 d postonset) magnetic resonance imaging (MRI) on disability and medical cost outcomes in patients with acute, disabling, ...work-related low back pain (LBP) with and without radiculopathy.
Evidence-based guidelines suggest that, except for "red flags," MRI is indicated to evaluate patients with persistent radicular pain, after 1 month of conservative management, who are candidates for surgery or epidural steroid injections. Prior research has suggested an independent iatrogenic effect of nonindicated early MRI, but it had limited clinical information and/or patient populations.
A nationally representative sample of workers with acute, disabling, occupational LBP was randomly selected, oversampling those with radiculopathy diagnoses (N = 1000). Clinical information from medical reports was used to exclude cases for which early MRI might have been indicated, or MRI occurred more than 30 days postonset (final cohort = 555). Clinical information was also used to categorize cases into "nonspecific LBP" and "radiculopathy" groups and further divided into "early-MRI" and "no-MRI" subgroups. The Cox proportional hazards model examined the association of early MRI with duration of the first episode of disability. Multivariate linear regression models examined the association with medical costs. All models adjusted for demographic and medical severity measures.
In our sample, 37% of the nonspecific LBP and 79.9% of the radiculopathy cases received early MRI. The early-MRI groups had similar outcomes regardless of radiculopathy status: much lower rates of going off disability and, on average, $12,948 to $13,816 higher medical costs than the no-MRI groups. Even in a subgroup with relatively minimal disability impact (≤30 d of total lost time post-MRI), medical costs were, on average, $7643 to $8584 higher in the early-MRI groups.
Early MRI without indication has a strong iatrogenic effect in acute LBP, regardless of radiculopathy status. Providers and patients should be made aware that when early MRI is not indicated, it provides no benefits, and worse outcomes are likely.
3.
Objective
Return-to-work (RTW) coordination has been suggested as an effective strategy for preventing workplace disability, but the scope of these services is not well described. The objective of ...this study was to describe the activities of RTW coordinators in published trials to provide a basis for establishing necessary competencies.
Methods
A keyword search of MEDLINE and CINAHL databases was conducted to identify intervention studies with a RTW coordinator providing direct, on-site workplace liaison to reduce work absences associated with physical health ailments. This search yielded 2,383 titles that were inspected by two examiners. Using a stepwise process that allowed for assessment of inter-observer agreement, 90 full articles were selected and reviewed, and 40 articles (22 studies) met criteria for inclusion.
Results
All but two studies (of traumatic brain injury) focused on musculoskeletal conditions or work injuries. Twenty-nine RTW coordinator activities were identified, but there was variation in the training background, workplace activities, and contextual setting of RTW coordinators. Based on reported RTW coordinator activities, six preliminary competency domains were identified: (1) ergonomic and workplace assessment; (2) clinical interviewing; (3) social problem solving; (4) workplace mediation; (5) knowledge of business and legal aspects; and (6) knowledge of medical conditions.
Discussion
Principal activities of RTW coordination involve workplace assessment, planning for transitional duty, and facilitating communication and agreement among stakeholders. Successful RTW coordination may depend more on competencies in ergonomic job accommodation, communication, and conflict resolution than on medical training.
Survey report.
To reassess an existing list of research priorities in primary care low back pain (LBP) and to develop a new research agenda.
Primary care LBP researchers developed an agenda of ...research priorities in 1997 at an international conference. In 2009, a survey was conducted to re-evaluate the 1997 research priorities and to develop a new research agenda.
Two-phase, Internet-based survey of participants in one of the LBP primary care research fora. The first phase collected information on importance, feasibility, and progress for the 1997 priorities; during this phase, the respondents were also asked to list the 5 most important current primary care-relevant LBP research questions. The second phase ranked these current research priorities.
A total of 179 persons responded to the first phase, representing 30% of those surveyed. Rankings of the 1997 priorities were somewhat similar compared with 2009, although research on beliefs and expectations and improving the quality of LBP research became more important, and research on guidelines and psychosocial interventions became less important. Organizing more effective primary care for LBP, implementing best practices, and translating research to practice were ranked higher compared with 1997. Most priorities were also ranked as relatively feasible. The new agenda was similar, and included subgroup-based treatment and studies on causes and mechanisms of LBP as new top priorities.
Changes in research priorities seem to reflect recent advances, new opportunities, and limitations in our ability to improve care.
Abstract Background Initial management of acute occupational low back pain (AOLBP) commonly occurs in the emergency department (ED), where opioid prescribing can vary from the clinical guidelines ...that recommend limited use. Objective The objective of this study was to explore how opioids are prescribed in the ED and the impact on work disability and other outcomes in AOLBP. Methods A retrospective cohort study was conducted. All acute compensable lost-time LBP cases seen initially in the ED with a date of injury from January 1, 2009 to December 31, 2011 were identified within a nationally representative Workers' Compensation dataset. Multivariate models estimated the effect of early opioids (received within 2 days of ED visit) on disability duration, long-term opioid use, total medical costs, and subsequent surgeries. Results Of the cohort (N = 2887), 12% received early opioids; controlling for severity, this was significantly associated with long-term opioid use (adjusted risk ratio = 1.29; 95% confidence interval 1.05–1.58) and increased total medical costs for those in the highest opioid dosage quartile, but not associated with disability duration or subsequent low back surgery. Conclusions Early opioid prescribing in the ED for uncomplicated AOLBP increased long-term opioid use and medical costs, and should be discouraged, as opioid use for low back pain has been associated with a variety of adverse outcomes. However, ED providers may be becoming more compliant with current LBP treatment guidelines.
Retrospective analysis of workers' compensation (WC) claims data for nonspecific low back injuries (LBI) in a single jurisdiction.
To examine whether recurrences, defined as post-initial episodes of ...work disability or medical care, substantially contribute to total medical and indemnity costs, and total duration of work disability.
Previous studies have not measured the proportion of care seeking and work disability that are associated with recurrences in claims for work-related LBI.
All persons with new lost-time claims for nonspecific LBI reported in New Hampshire to a large WC provider from 1996 to 1999 were selected (N = 1867). Three years of follow-up data, starting at the beginning of the first episode, were collected. Previously validated definitions of recurrence were used identify new episodes of care and new episodes of lost work time (work disability). Total duration of work disability, total medical costs, and total indemnity costs were investigated. For individuals with recurrences, these variables were separated into first-episode and recurrent period duration and costs.
The rate of recurrent work disability was 17.2%, and the rate of recurrent care seeking was 33.9%. Individuals with recurrence had significantly higher total length of work disability, and higher medical and indemnity costs. For those with recurrent work disability, 69% of total lost time from work, 71% of associated indemnity costs, and 84% of total medical costs occurred during the recurrent period. For those with recurrence of care, the respective values were 48%, 47%, and 42%.
Recurrences contributed disproportionately to the total burden of work-related nonspecific LBI, through both additional care seeking and work disability. Results imply that those who have recurrences may be an especially important target for secondary prevention efforts.
Objectives We investigated multiple trajectories of the probability of reporting health-related productivity loss over a 20-year period among adults aged 25-44 years and explored differences among ...the trajectories in demographic and personal characteristics and employment outcomes in midlife. Methods A latent class growth analysis of health-related productivity loss was estimated on 12 waves of data from the National Longitudinal Survey of Youth (NLSY79) (N= 5699), an ongoing nationally representative longitudinal survey of Americans. Waves 1-5 were collected annually at ages 25-29 years. Waves 6-12 were collected biennially at ages 30-44 years. Productivity loss was measured as "health fully preventing a person from working" or "health limiting the amount or kind of work a person could do". Differences among trajectories were assessed using analyses of variance (ANOVA) and Chi-square tests. Results A five-group trajectory model for productivity loss was identified: (i) no risk, (ii) low risk, (iii) high risk, (iv) increasing risk at early ages, and (v) increasing risk at later ages. At the first wave, after the waves used for the trajectory model in which respondents were approximately age 45 years, the no-and low-risk groups worked the most weeks and hours per week and had the highest percentages of participants employed ≥10 weeks compared to the high-risk and early-/late-onset increasing-risk groups, all of which had the lowest levels of mastery, self-esteem, education, and socioeconomic status. Conclusions There are several developmental patterns of productivity loss, with some trajectories being associated with lower work participation in midlife. These high risk patterns may be indicative of individuals needing intervention to prevent premature work withdrawal.
The impact of musculoskeletal disorders on work is demanding more attention from clinicians. For many rheumatologists, inflammatory arthritis is the most frequently encountered condition that ...interferes with work. However, the cumulative burden of non-inflammatory arthropathies and disorders such as back pain, osteoarthritis and limb pain as a whole results in a much greater economic and human cost to society than inflammatory disease. New conceptual approaches and research results support the view that work loss does not need to be a frequent consequence of a musculoskeletal disorder or disability. This is often accomplished through a biopsychosocial and interdisciplinary approach, involving interaction between those with a musculoskeletal condition, their clinicians and employers. This review outlines the challenges and draws on the results of empirical studies to highlight potential opportunities to promote sustained ability for patients to successfully remain on the job. It also outlines future research opportunities.
Early magnetic resonance imaging (eMRI) for nonspecific low back pain (LBP) not adherent to clinical guidelines is linked with prolonged work disability. Although the prevalence of eMRI for ...occupational LBP varies substantially among states, it is unknown whether the risk of prolonged disability associated with eMRI varies according to individual and area-level characteristics. The aim was to explore whether the known risk of increased length of disability (LOD) associated with eMRI scanning not adherent to guidelines for occupational LBP varies according to patient and area-level characteristics, and the potential reasons for any observed variations.
A retrospective cohort of 59,360 LBP cases from 49 states, filed between 2002 and 2008, and examined LOD as the outcome. LBP cases with at least 1 day of work disability were identified by reviewing indemnity service records and medical bills using a comprehensive list of codes from the International Classification of Diseases, Ninth Edition (ICD-9) indicating LBP or nonspecific back pain, excluding medically complicated cases.
We found significant between-state variations in the negative impact of eMRI on LOD ranging from 3.4 days in Tennessee to 14.8 days in New Hampshire. Higher negative impact of eMRI on LOD was mainly associated with female gender, state workers' compensation (WC) policy not limiting initial treating provider choice, higher state orthopedic surgeon density, and lower state MRI facility density.
State WC policies regulating selection of healthcare provider and structural factors affecting quality of medical care modify the impact of eMRI not adherent to guidelines. Targeted healthcare and work disability prevention interventions may improve work disability outcomes in patients with occupational LBP.
PDF
